Necrotizing Fasciitis!! or maybe just Cellulitis…

“Nec Fasc” is one of those diagnoses in medicine that makes surgeons sweat bullets, ER docs pump antibiotics like firehoses, and sends interns screaming into phones to set up emergency surgery STAT.  We had a patient where this was a concern, he’d let it go due to the fact he was sooo close to finishing Hellweek as part of his SEAL training- and he made it!  But like most guys I’ve seen from this training, they are so cut up, beat down, and pushed so far past their limits you just have to sit back in awe at what they’ve done to their bodies.  Stress fracture?  That’s nothing!  Pneumonia?  Who cares!  Keep going!

Anyway, I got a few key pointers about telling the difference between nec fasc and cellulitis.  These are just things someone educated me about, I didn’t pull this from the 7th edition of a textbook or a randomized controlled double blinded study,  so take it for what it is.  Cellulitis is MUCH less concerning, though also usually requires hospital admission with antibiotics and can also be devastating in the long run.  So here were a couple physical exam pointers that can either raise your blood pressure or calm those 4 AM frayed nerves:

1.)  Erythema:  Present with both, but in nec fasc the infection in the fascial plane spreads faster than the erythema above it.  Therefore, patients often complain of pain beyond the erythematous border.  In cellulitis, pain is typically only present over the affected skin.

2.) Palpation: If there’s crepitus, think nec fasc.  I’ve felt crepitus before (from a botched chest tube placement) and it seriously feels like there’s crinkled cellophane just below the surface of the skin.  Others have described it as rice krispies, which is also close.  It actually feels like popping and snapping when you press down!  Lack of crepitus doesn’t rule out nec fasc though- it can still be an emergency situation if all you feel is the classic hot, swollen, painful skin.  Remember it depends on the organism causing the infection…

3.) Vital signs: Tachycardia may be the only change.  Especially in young, healthy patients (like in the military population) their body can compensate for infection for quite a while.. until a sudden crash that was unanticipated lands them in the ICU.  On exam, patients can appear to be doing well, but don’t let that fool you!  All that “badness” growing at exponential rates will hit a threshold the body can’t handle… and then you’re dealing with full blown Shock.  No thanks.  Watch your vitals carefully!

4.) Labs: Obviously infection will make your white count go up.  However, in the experience of most residents I’ve spoken with, ned fasc will raise it dramatically and usually above 35.  Of course, it depends on the time of presentation and immune status of the patient but if the lab starts calling you with critical values, that might be a sign that something critical is happening.

With the SEAL I saw, when I evaluated him in the emergency room, I drew a line at where the erythematous border was though he was already receiving antibiotics.  Being on ortho, I was there to rule out compartment syndrome (due to pain out of proportion to exam) but I quickly ruled that out since the skin was pretty soft.  Surgery decided to take him to the OR, where I saw him 1.5 hours later and was astounded at how far past my markings the erythema had progressed!  He had alredy received about 5 different IV antibiotics and still the infection was advancing.  In some places, it was almost an inch.  Holy smoke Batman!!!

The surgeon made an elliptical incision over where some new petechiae had shown up on the skin, often being a clue as to where the worst underlying infection may be.  I heard him teaching the resident that (only read on if you’re a surgeon or have a strong stomach) …. if it’s nec fasc, expect “dishwater discharge” when making the incision.  When palpating the fascia, run your finger up and down the incised areas and if it’s intact, that’s good.  If it breaks apart as you push, that’s bad.  That’s when you being the unzipping process and debride, debride, debride.  Then drink a couple RedBulls and Rockstars because you’re not going to get any sleep on the frequent post-op checks.

My patient did not have nec fasc, in case you’re wondering.  They just did the 2 elliptical incisions, packed and left them open, and kept pumping him full of antibiotics and fluids.  Phew

 

Dirtbikes cause fractures: Pelvis and Scapula

This is the second call I’ve gotten about fractures and dirtbikes.  The first was someone I saw who raced up a sand dune only to find the back was not there.. and he fell 20 feet onto his bike, fracturing his pelvis- which is a hard thing to do!

Today I saw a scapular fracture, it was a guy who went over his handlebars and now can’t raise his arm above his shoulder.  Apparently this is expected after fracturing your scapula.  Treatment for a fracture that’s still relatively lined up (non displaced) is to just keep it in a sling for a few weeks, but keep flexing the elbow so as not to lose muscle tone or develop any other disuse symptoms.  After 3 weeks, having someone move the shoulder (passive range of motion) should help regain strength in the shoulder.

Surgical indications are if the fracture is displaced, involves the articulation with the humerus, and some coracoid process fractures.  As I got sent home sick today and am miserably typing from my couch and don’t have the energy to look in my Handbook of Fractures, I can add more later.  Right now I’m going to blow my nose and take a nap instead.

…. The only thing I thought to add is that I’d like to try dirtbiking some day.  Seriously, no sarcasm!  I accidentally got my ninja on some sand, it freaked me out for a sec when it fishtailed and I worried about how junky my chain would get but if I had a dirtbike I bet you could take some badass curves and the lack of roadrash would be a plus!

 

On call- Fractures! Compartment syndrome!

The fun thing about being on call is when you realize you don’t care that this patient has kept you from getting sleep, it’s the coolest case ever!

We had a patient come in just as my resident and I had tidyed everything up, seen and written notes on 3 broken arms, done our post-op checks, and had already said “goodnight, hope we get some sleep..”  Just as we were exiting the elevator, the emergency room number pops up     But when I saw the X-ray, that frowny face turned into a smiley face!!  (Did I mention I love trauma?)

It was a fracture known as “comminuted” because there were a bunch of fracture lines creating multiple pieces of bone . Because the limb was turned at an obviously weird angle, we gave a mix of fentanyl and propofol for pain control, brought in the fluoro machine ( live x ray vision!) and had our plaster splint on standby.  Then we pulled on it to straighten it out, which is known as reducing the bone.  Given the past reductions I’d seen, I expected to have to really tug hard to get the pieces back together. Instead, it moved almost too well!  I guess when you have bones in that many pieces you don’t have to force it.

The only thing is, I recently saw a patient who had a lot of muscle taken out of his leg after a fracture that led to “compartment syndrome.”  When this happens, the swelling gets so bad that you cut off blood supply to a bundle of muscles within that compartment.  The fascia and skin create an almost tourniquet-like effect and the muscle can die within 24 hours.  Because this new case was so severe and had so much swelling, I was really, really worried that this fracture might progress also.  On admission I placed orders for neurovascular checks every 2 hours to make sure there were still pulses and sensation beyond the fracture site but still went to sleep biting my nails…

So, I learned a little bit and was able to expand my knowledge on the classic compartment syndrome’s “pain, pallor, pulselessness, parasthesia, and pain out of proportion”  Though the compartments were really tense from all the swelling, it wasn’t compartment syndrome.  I hear it’s pretty obvious when you find compartment syndrome on physical exam (the leg/arm will feel like a block of wood.  Really!) But it’s scary nonetheless when you see such a severe fracture with so much swelling!  I’m glad I had someone there to tell me NOT to do a fasciotomy, if I was in the middle of Afghanistan on my own and this happened to one of my marines….I still would have waited but I’m just glad everything turned out ok today

… 1 week later…. After I left post-call, I heard that they did end up taking this patient to do a fasciotomy, but no muscle tissue seems to have been compromised.  Compartment syndrome is a clinical diagnosis, though you can use a Stryker compartment pressure machine to get actual numbers.  This is used more in exercise-induced compartment syndrome because patients will occasionally consent to having long needles inserted into their muscles for this kind of evaluation.

 

Things I learned today

As I no longer eat dinner with the nuclear family and have the question put to me by my parents “so, how was school today?  What did you learn?”  I thought it might be a fun experiment to post something to that effect on this blog.  Today was a learning-filled day, here are a few:

1.)  Blummensaat’s line: A radiographic landmark of the knee at 30 degrees flexion, a line drawn at the distal femur’s cortical line that should extend out inferior to the inferior border of the patella.  If the line intersects the patella (and the insall-salvati ratio is less than 1.0) you suspect patella baja, and thus a quadriceps muscle rupture.

2.) Anyone who tells a hospital-admitted marine recruit (who has never gone through MC training himself)  anything to the effect of “Do you want a straw?  Suck it up!” is a complete tool.  TOOL.  Just because you’re a pudgy navy officer doesn’t mean you should be a jackass to an injured recruit.  Please, I saw you almost die at the end of a 1.5 mile run….

3.) Knowing I can easily find parking within 1 block of a downtown bar with my motorcycle has greatly improved my outlook on socializing downtown.  MUCH less anxiety about the anticipation of frustration with parking and circling and fighting over pavement and scoping and tailing people down the street and shelling out $20 because of a Padres game and etc.