Friday, November 09, 2007

Update on skin and soft tissue infections

An excellent and thorough review of this topic recently appeared in CCJM as part of its supplement on Infections in Hospitalized Patients. With the increasing severity of illness of hospitalized patients and the rise of community associated MRSA, clinicians must be vigilant for necrotizing infections and the need for surgical consultation. The review covers clinical assessment for necrotizing infections and cites this study from Critical Care Medicine describing a scoring system of laboratory parameters to assess for necrotizing fasciitis. Although the scoring system is not detailed in the abstract of the Critical Care Medicine paper it can be accessed in this open access full text paper from Current Opinion in Infectious Diseases.

1 comment:

John Morton said...

Hey Doc.
Thanks for posting one of the most commonsence commentary about necrotizing facsiitis. My wife is healing from a month of in patient therapy that started after spending a week end being 'treated' by her primary care and his back up - his old friends in the local doc in a box for what started off as a sore shoulder, increased to a painful outbreak Shingles across the top of the shoulder except for the fact that there are no nerves across the top of the shoudler where her pustule and necrotic blisers were developing. It had to be something that those diabetics get all the time just because they are diabetic right?

We'd tried to get an appointment for her terribly painful right sholder on the Friday going into the weekend and were told the there was no way he could see her til monday at the earliest...n but that his old firends at the doc-in-a-box clinic where he used to work wold be happy to cover for him in the meantime and until we could see him at 4:30 on the following Monday. I called sunday to tell him that she was in severe pain and he said that the swelling and pain in the shouder was worsening and he said that we needed to increase the pain meds from 10 mg oxycontin to 20 mg oxycontinc. We did and the pain seemed to abate somewhate while her shouder got darker and greener and more and more swollen
By the time we got to the appontment time at 4:30 on MOnday afternoon, her blood sugar was above 800 and she was unresponsive to questions and her skin was clod and clammy and she looked very shocky. We went to the doctors office to make the 4:30 appointment. I went in and asked for some help getting her into the waiting area. I was told no, they would not help me.

I asked after going out and coming back in if they could loan us his wheel chair so that my step son and I could wheel her into the office so he could see her. I was very affraid that these 'shingles' that she had been diagnosed with were killing her with the fever and chills that had come with it.

Again I was told that no, they had no wheel chair I could use.

I went back out to try to determine just how I was going to get my very shocky and ill wife up the steps or up the ramp to get into his office so hs could see her...I went back in and asked if there was anyone... a nurse... a doctor who would be willing to go out into the parking lot to see my wife... and i was told by someone in apparent authority that nobody would go outside into the parkinglot to see her and that if I didnt feel she could wait to see the doctor at her appontment time, then I may want to consider taking her to the nearest Emergency Room.

In a statement like that it is understood by us laymen non medical personel to hear that as,"If in your limited medical expertise, feel you are smarted than the doctor and you don't want to wait your turn to see Doctor then you are wecome to cancel your appoinment (which we really wish you'd cancel with at least 24 hours notice) and you can take her say for example - the emergency room."

I said that it sounded like a great idea and at that moment I had only one message to pass on to the dear 'Doctor'
"You - all of you - are fired."

I then sped with all due haste to the nearest ER where she was admitted and eventuyally moved to a room at 2am Tuedsay morning. Her blood sugar was in excess of 800 the the first thing they were trying to do was to get her Diabetis under control before doing anything else.

At 4pm Tuesday afternoon, the Soft tissue surgeon had just reviewed the wound and the xrasy and CT Scans and asked the nurse there in the ICU to get the patient ready for suregery.

"Tomorrow morning?" she asked.
"No. Now RIGHT NOW. There is not time to waste if we are going to save her."

She went into surgery at 4:00 and came out at 4:45 without most of her right shoulder and many of the nerve,vascular and muscular elements needed to life a heavy box or turn your head fully to the right or left. The bacteria had already started reaching into her breasts, back, shoudler and then deeply up her neck and to, but not through the thoracic cavity. You can watch her main arteries of her neck pulse nakedly as it keep her head and heart alive and beating.

Can anyone... anywhere expalin her PCP's behavior in any way that could make sense to an average person? Or did this guy just behave so completely crazy simple because he can and there are no consequences for him being an ass.

Is there simple level standard of care that has not been met here in terms of his relationship to his greatments (or mistreatemts) sonsidering the very real life or death battle he had going on in this patient - one he'd convinced himself was a case of Shingles and was jsut an attempt by this patient to get pain medicines... there is so much of that here in the Southwest Indiana.

Is anyone at fault? What abou the husband of the patient. Why didn't understand that she was not getting any care at all and that she was dying and needed good medical attention STAT! What about him? Wouldn't a reasonable person have been able to see it was so much more than Shingles and in turn seen that he needed to get her to an emergency room? Or not.

If the patient is slightyly autistic or retarded and unable to clearly communicate with her caregiver... whose at fault. What if the patient has a history of having had MRSA before in the past and this is a past all of the clinicians were made aware of right from the start.

How can we fix a sysetm that is trying to get people to stop demanding antibiotics and running off to the emergency room at the first sign of any infection or sore. NRSA is our own undoing. Be prudent about running to doctors demanding antibiotics. Give it a day or two to see how bad it really is. What's a couple of days going to matter anyway.

When you are thinking this way....
people can die if they follow that line of thinking.