Holy tired. I have worked the past 7 days straight and after not having a weekend, made me realize how important those precious two days are to my mental health. I'm so thankful to have the day off today to catch up on sleep, laundry, and school work.
Let me tell you about one of my most interesting/awful/"you will probably never see this" cases this week. I'm sure everyone in my PA program remembers the very graphic slide during the urology lecture with the heading "Fournier's Gangrene." If you don't, google image it...I'm pretty sure the "you will probably never see this" line came shortly after but I could be wrong, or maybe I was just hoping I would never have to see it. So, when I was handed my patient list and saw "Fournier's Gangrene" as the reason for admission my heart sank.
Basically, Fournier's Gangrene is necrotizing fasciitis of the perineum...usually in men, but from what I've read there is a type that has affected women too. So, this poor man (who I might I add is the most kind-hearted man and has the best attitude I've ever seen) wakes up a couple weeks ago on a Saturday and felt like he had the flu, just didn't feel good but didn't think much of it. He noticed he had a bruise on his butt but couldn't remember hitting anything or any injury. Fast forward to the following Wednesday and he still doesn't feel well and the bruise is getting bigger. He decides to go to a family practice office who thinks it is probably an abscess or cellulitis and gives him oral antibiotics but does some lab work just in case. Lab work comes back really not okay and the doctor worries based on his clinical presentation and lab work that he could have a really bad infection and sends him to a local ER. He is immediately taken to the OR for two debridements at the local hospital. That hospital just did not have a good feeling as the scrotum was now becoming involved and the infection was spreading rapidly. He is transferred to Methodist and again immediately goes to the OR for another debridement. He is in the ICU for a couple days and then gets his 4th debridement. Throughout this time he has been medically stable after his last debridement they transfer him to the PCU where I pick him up.
The first time I saw him, he was covered up and his wounds were dressed so I couldn't see the severity of the infection/depth of the debridements. He was still medically stable so I honestly just sat with him for awhile, but he had some leg pain so we worked that up to make sure the joint was getting infected, thankfully that was all okay. I asked the PT wound team if I could be called when they dressed his wound so I could examine them and watch how they did it. I think my jaw dropped open. I don't know how this man could endure such pain with such grace and kindness. The majority of his right buttock had been removed, at least superficially, which extended down into his perineum where again the majority of his scrotum had been removed. His testicles were free exposed without any covering other than what the wound care team could provide. The wound continued to extend up the lateral aspect of the scrotum into the left side of his mons pubis. To say it was horrific was an understatement. No one on the internal medicine team had seen anything like it.
His cultures grew a very sensitive strand of E.Coli thank God, so the his IV antibiotics were able to knock out the infection to stop the spreading. All his blood cultures were negative. The wound care team took such great care of him and were so gentle and thorough. The major problem/concern which led to quite the debate between the surgeons vs. everyone else was what was going to happen when this man had a bowel movement. The wounds only spared the rectum by two finger breadths. He already had a suprapubic catheter in place, and would for a long time, but the majority of those taking care of him thought he needed a diverting colostomy placed so he could have bowel movements without worrying about contamination. The surgeons did not agree and did not want to go that route and thought he should be able to have BMs and be cleaned up immediately following and to discuss the colostomy if contamination became an issue. So far it hasn't....I just worry about him when he is transferred to a small rehab facility if they will have the staff on hand to provide him with such prompt care every time he uses the bathroom. He has already had a consult with the plastic surgery team so that when the time comes he can have a scrotum reconstructed...that is a ways down the road though as his other wounds try to heal.
He has such a long recovery process ahead of him I almost can't imagine how he can think about the future. Again, you wonder why bad things happen to good people....its really hard to wrap your head around it sometimes. He is an incredibly special person and I know he will get through this, but I'm sure he will have bad days when he is so mad and frustrated and in pain and I just hope he is taken care of once the way he deserves once he leaves Methodist.
So, I'm not happy I saw a "you will never see this" case, but it was a great learning experience. I learned about wound care, and cultures and antibiotics and pain control from the hospital setting...but from the patient I learned so much about gratitude and strength. He would say "thank you" after his wounds were dressed and he was biting his finger so hard through the pain I thought it would bleed. If I'm ever a patient I hope I will treat the staff as kindly as he did, what an incredible person.
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