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After treating an emergency department patient with an infected left lower extremity secondary to necrotizing fasciitis, Dr. Obremskey himself was stricken with the disease. Although the patient succumbed, Dr. Obremskey survived.
Courtesy of Dr. Obremskey

AAOS Now

Published 10/1/2011
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William T. Obremskey, MD, MPH; Jill Obremskey, MD

To the edge and back

My battle for life was a lesson in living

As a trauma surgeon, I am frequently called into sudden action and have grown accustomed to the emergent nature of my profession. But little did I know that a routine Monday morning call would change my life and ultimately lead me to adopt four critical principles of living.

The day began with a page from a colleague requesting my immediate presence in the operating room (OR). The patient was a young man with an infected left lower extremity, secondary to necrotizing fasciitis (Fig. 1). Although I have treated patients with this disease before, I am always struck by its lethal abilities.

The patient had walked into the emergency department just hours before with a history of a deep bruise, the result of a cinder block landing on his thigh. Very quickly, what are commonly known in the lay press as “flesh-eating bacteria” and “toxic shock syndrome” developed. After we removed all of the deep tissue affected by necrotizing fasciitis from his left leg, we saw that the entire extremity was necrotic. In a final attempt to save the patient’s life, my colleagues and I decided to perform an emergency hip disarticulation and remove the entire left leg.

Unfortunately, during this process I was stuck in the left hand with an electrocautery knife. I followed hospital policy and removed my gloves, cleaned and dressed the wound, scrubbed up again, and returned to complete the operation. The patient and I were both checked for diseases such as HIV and hepatitis C; neither of us showed any evidence of these common blood-borne diseases. In the following days, despite our best efforts, the patient succumbed to his infection.

From physician to patient
The entire next week for me was fairly routine. The needle stick on my left hand appeared to be healing without a problem and I worked a regular week. But 10 days later, I felt like I had a viral illness and struggled through my day in the OR. The following morning I cancelled clinic—certainly a sign that I wasn’t well—and within a few hours I noticed increasing redness in my foot and some swelling on my right thigh. I asked one of our residents and one of my partners to examine me and quickly found myself as a patient.

My colleagues ordered a blood workup, as well as radiographs and a magnetic resonance imaging scan of my right hip (site of a previous total hip replacement) to see if any fluid, which might be an indication of infection, could be found. The joint was not infected, but the lymph nodes of my right groin and knee were inflamed, and the redness had progressed over my leg.

A consultation with an infectious disease colleague resulted in my admission to Vanderbilt University Medical Center and a course of IV antibiotics to treat what was assumed to be early cellulitis or lymphangitis.

That decision marked the end of my conscious memory. The remaining details have all been filled in by my wife, Jill Obremskey, MD, a pediatrician.

Over the next few hours, my clinical condition worsened. While I was not yet critically ill, I was exhibiting mental status changes and becoming sicker by the minute. My wife, who was deeply concerned about my dramatic and precipitous clinical progression, initiated a long series of ultimately lifesaving decisions by asking a friend, the director of the Surgical Intensive Care Unit (SICU), to evaluate me. He immediately realized that I was septic and needed to be transferred to the SICU.

A steroid “cure”
As my clinical condition declined, we exhausted medical treatment options. Much like the patient whom I had treated days earlier, I was taken to the OR. There, the surgeons found that the infection had spread throughout my foot and traveled up the lymph nodes behind my knee into my medial groin due to “necrotizing fasciitis.” Furthermore, “toxic shock syndrome” was developing, with evidence of acute respiratory distress syndrome, renal failure, and liver failure. I returned to the operating room multiple times over the next 48 hours.

esh Eater.gif
After treating an emergency department patient with an infected left lower extremity secondary to necrotizing fasciitis, Dr. Obremskey himself was stricken with the disease. Although the patient succumbed, Dr. Obremskey survived.
Courtesy of Dr. Obremskey
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Dr. Obremskey (right) and his wife, Jill Obremskey, MD, a pediatrician, are glad the episode is behind them.
Courtesy of Vanderbilt University Medical Center/Anne Rayner

Ultimately, the collaboration and collective experience of my surgical colleagues saved my life. The chief of staff made a novel suggestion: a high-dose steroid treatment (dexamethasone) for 2 days to blunt the effect of the toxins on my kidneys, lungs, liver, and heart and to give my body and the antibiotics some space and time to begin to fight back. Luckily for me, he had treated patients with toxic shock syndrome for more than two decades and found that this treatment, although controversial, could be effective.

Within 24 hours I began to improve. Three days later, I heard “spit real hard and we will take that breathing tube out.” I did as instructed and was suddenly breathing on my own, an activity that I once had taken for granted.

I remained in the SICU for the next 48 hours—a period of partial consciousness, delusions, and hallucinations. My most vivid hallucination was that my son had returned to Nashville and given me an iPod to use in the intensive care unit. The memory was so vivid that when my bedding was changed, I frantically searched for the device and asked the nurses several times to help me find it.

Lessons for life
In my 20 years as an orthopaedic trauma surgeon, I have helped care for several people with necrotizing fasciitis and toxic shock syndrome. Up to 70 percent of patients do not survive this diagnosis; many of those who do survive are missing parts of limbs.

I was lucky; although I had several wounds on my foot and one that extends from the back of my knee to my groin, my muscles, nerves, and long-term leg function—after hard work with physical therapists—are now normal. Surprisingly, although DNA-typing found the bacteria to be identical to the initial patient, my condition had nothing to do with the electrocautery wound I sustained in the OR. Consensus is that I breathed in the bacteria in the air and became an asymptomatic nasopharyngeal carrier of the Group A Streptococcus, which infected my foot through an athlete’s foot wound.

My battle with necrotizing fasciitis and a related median nerve palsy kept me out of the OR for 6 months as I regained my strength. But this forced hiatus gave me time to reflect on what had happened to me and how this experience could help me move forward. Many people have asked if the experience has made me a better doctor; to be frank, I do not believe that it has. My mother instilled in me the importance and gift of connecting with people, understanding their life stories, and, most importantly, meeting their needs as patients who have sustained trauma.

However, the experience has enabled me to identify with the anxiety and fear that patients experience when their lives are turned upside down and the outcome is uncertain, and I believe I am a more empathetic and compassionate physician for that reason. I do like to show patients that I wear compression stockings due to chronic leg edema and offer to compare scars.

It is clear to me that people need a purpose to sustain a meaningful life. How each individual accomplishes this is a personal decision. For me, the battle with necrotizing fasciitis provided four lessons to guide my daily life.

  • Stay healthy, have a strong heart, and stay alive. I am sure that I would not have survived this condition if I had not been in pretty good physical condition and had a strong heart. It is too easy to get out of shape, and the long-term consequences can be deadly.
  • Hug your spouse, children, and loved ones daily because you never know when you may not see them again. As a dog lover, I believe we should love those around us as our dogs love us: unconditionally and constantly.
  • Try to do a little good in the world every day, one person or patient at a time.
  • Look at the cup of your life as half full, because it can always get worse. But take time to enjoy some half-full cups of red wine, relax with some beautiful sunsets, and enjoy the journey of your meaningful life.

I hope that this experience has made me a better husband, father, son, brother, uncle, and friend. As I try to live these lessons, I recall a Garth Brooks song. He said it best: “Is the love I gave her in the past gonna be enough to last if tomorrow never comes?”

William T. Obremskey, MD, MPH, is an orthopaedic trauma surgeon at Vanderbilt Medical Center. His wife, Jill Obremskey, MD, a pediatrician, is an instructor of emergency medicine at Vanderbilt.

References:

  1. May AK, Daniels TL, Obremskey WT, Kaiser AB, Talbot TR III: Steroids in the treatment of group A atreptococcal necrotizing soft tissue infection. Surg Infect (Larchmt) 2011 Feb;12(1):77–81. Epub 2010 Dec 20. UI: 21171810
  2. Chiu CH, Ou JT, Chang KS, Lin TY: Successful treatment of severe streptococcal toxic shock syndrome with a combination of intravenous immunoglobulin, dexamethasone and antibiotics. Infection 1997;25(1):47–48.
  3. May AK, Stafford RE, Bulger EM, et al: Treatment of complicated skin and soft tissue infections. Surg Infect (Larchmt) 2009;10(5):467–499.
  4. Stevens DL, Bisno AL, Chambers HF, et al: Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis 2005;41(10):1373–1406.