A Dirty Wound Can Be Dangerous

During my recent family holiday, we took a day trip to a very small island of Barbuda. Barbuda is a flat coral island with an area of only 68 square miles. The island’s population of 1500 live in the village of Codrington. It is renowned for its beaches which are natural, sprinkled with pink sand, and miles long.

We were with a group of other tourists including a family doctor from England who stayed at the same hotel as we did and knew I was a surgeon. So, here we are, climbing rocks and exploring a cave. I turned around to take a picture, tripped and fell on a rock. My right leg sustained a deep nasty dirty wound with blood gushing all over the place and a piece of my precious skin and flesh lying on the bloody ground.

There was momentary panic amongst my fellow tourists when the English doctor announced with confidence, “Don’t worry, he is a surgeon!” That lightened the situation with several people offering their shirts to use as a bandage to stop the profuse bleeding.

In my mind I knew this was a serious situation. I immediately thought of two very life threatening outcomes from this episode, loss of limb or life from tetanus or flesh-eating disease. Before my trip, I had a booster dose of tetanus toxoid vaccine. But what about flesh-eating disease?

Flesh-eating disease is a form of streptococcal infection that leads to death of tissues. It is a deep-seated infection under the skin. It progressively destroys fat, fascia and muscles. The condition is also known as necrotizing fasciitis.

Streptococci (invasive group A hemolytic streptococci) may act alone or in combination with other bacteria. The infection spreads rapidly. Shock and multi-organ failure are common. Mortality is high, up to 58 percent.

Fortunately, the disease is not that common. In Canada, it is estimated that 90 to 200 cases of necrotizing fasciitis occur each year. From time to time the disease hits the headlines. Then there is long silence before another case is reported. This leaves people wondering what is this all about.

The most famous case of flesh-eating disease was Loucien Bouchard, the former premier of Quebec. He luckily survived and had to have one leg amputated.

It is not a new disease. The condition was first described in a specific body region by Fournier in 1883 and as a more generalized condition by Meleney in 1924.

Early diagnosis of this condition is not always easy. The diagnosis is clinical. Initially, it is hard to differentiate from ordinary infection of the skin. But gradually patients get very sick. The pain is more severe than the clinical findings. There are only minor changes in the skin in early phases. Unfortunately, the current state of knowledge on diagnoses and management is limited.

If the diagnosis is in doubt then surgical exploration is the best way to go. The characteristic finding is of grey, edematous fat, which strips off the underlying fascia with a sweep of the finger. Deeper changes are invariably more widespread than the skin changes.

Tetanus and flesh-eating disease are two extreme examples of how small things can get out of hand if no action is taken right away. There are many other kinds of infections which can affect dirty wounds. Even clean wounds like surgical incisions can get infected. Although the incidence of that happening is very low compared to a dirty wound.

If you sustain a dirty wound, including stepping on a dirty nail, make sure the area is thoroughly cleaned, your tetanus vaccine is up-to-date, you receive appropriate antibiotics to prevent infection and carefully monitor the progress of the wound. Before you travel abroad, make sure all your vaccines are up-to-date. Freaky things happen when you least expect it.

As for my leg, it is still there. The healing process is slow but I think I will be alright.

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