Necrotizing Fasciitis

I saw a man with necrotizing fasciitis today.* This is a medical student's dream; the grand hoo haw of infectious diseases. Nec Fasc is not something that you come across every day. It's the joy of being a med student that every practicing doctor wants to show you this crazy thing they just found. They haven't seen anything like it in all their years of practicing, and there you are, lucky enough to be a student and the receptical of all things educational. Our job is to be enthralled, inquisitive, and to validate their excitement. We reassure them that this is fascinating, we confirm that this is important, and perhaps our learning injects some hope into what might otherwise be merely a tragic incident; a sad waste. But that might be vanity speaking.

So back to this man I saw today. I got chills tonight, a momentary tear in my eye when I thought about what I had actually seen. It was not just necrotizing fasciitis. It was not just an infection superimposed on an already feeble, ill man. It was this man's death that I saw. The way that his life will end laid out on his body like tarot cards predicting the future. By the time he was diagnosed, 8 hours after admission, the flesh-eating bacteria had attacked too much of his already crippled body. Down one leg, up his back, weaving it's way down his other leg. Like a wave in slow motion, yet so fast, too fast for his body, for our medicine. There was nothing to be done except treat him for pain, treat him with antibiotics for palliative care, and help him die. And that's what grabbed me tonight. I saw this man for, at the most, 5 minutes, but he made an impact on me and not just because I had never seen necrotizing fasciitis before. He's the first person I have had contact with in the hospital who I know is going to die in the next several hours. And what's more, I know what he will die from. In my brief time in the guts of the clinical world, I have met many patients who I know are not long for this world. I know that we are merely postponing their death, but I do not know which one of their 10 problems will finally claim them. So even though we know they will die soon, we are ignorant about what they will die from, and the patient and the doctor(s) are gifted the freedom of continuing on in the charade, blissfully naive to the ending. Seeing this patient was like watching Hamlet after having already seen it. There is nothing to do but simply wait for the ending that you know by heart. You want to run up and console Ophelia before she drowns herself. You want to pull the poisoned glass from Gertrude's lips before she drinks. You want to reconcile Hamlet and Laertes before they stab each other. But you can't, because the show must go on (or so they say), and the ending always comes, and it always comes in the same way.

And so I know that tonight, at 10:45, the infection has now completely consumed both of his legs. It has moved onto his upper body. I am almost certain that he has finally developed sepsis and possibly fallen into unconsciousness. It is quite likely that, at this hour, roughly 24 hours after coming to the emergency room, he has succumbed to the ultimate, irreversible outcome of such tissue destruction.



*Necortizing fasciitis is one of those things that really scares me - both from a doctoring stand point and from a patient stand point. In other words, it's something I'm worried I'm going to miss in a patient and something I'm petrified that I am going to acquire. It's also something that fascinates me. I get the same chills up my spine, the same obsession/revulsion feeling about it as I do about deadly snakes and sororities.