The_Invention_of_Surgery

Krispies. My stomach drops, and while I don’t have much experience or
judgment in the practice of surgery, I know this is gas gangrene, the
byproduct of “flesh-eating” bacteria. There are classes of bacteria that
are infamous in causing rapid infections that result in the death of the
body’s soft tissues, so-called “necrotizing fasciitis,” with the occasional
byproduct of “subcutaneous emphysema,” or gas underneath the skin. The
physical exam finding of subcutaneous emphysema is frightening, to say
the least.
I gently place Mr. Louis’s arm back on the pillows, knowing that I am
seeing my first case of “nec fasc”—pronounced “neck fash,” in common
parlance. (This is how residency works—you can read all about
subcutaneous emphysema and necrotizing fasciitis, but until you have
someone’s limb in your hands with crunchy air underneath the skin, you
have not been properly initiated. Somehow the numbers work out.
Relatively rare, every surgery resident has seen nec fasc.)
I turn to the nurse and say, “necrotizing fasciitis.” All conversation
stops and everyone freezes.
“Really?” she says.
“Yes. I’m going to call Dr. Moulton, my senior resident.”
Connecting with Mark Moulton, I explain the details of the case.
Getting to the point, he asks me, “Are we early enough to save his arm or
will we have to amputate?” I confess to Mark that I really don’t know, that
I don’t have any experience. Mark tells me to get the patient rushed to the
operating room immediately. We will try and save Mr. Louis’s life, if not
his arm.
A flurry of phone calls to the operating room and the anesthesia team
achieves the impossible, and we are rushing to the OR within half an hour.
Life is on the line. The rest of the orthopedic team has made its way to the
hospital by 3:00 A.M., and my boss, Dr. Spence Reid, quickly concludes that
an amputation is mandatory. In the pre-op holding area we get a portable
X-ray that reveals air going all the way to the shoulder. Typical for
necrotizing fasciitis, the bacteria are on a warlike march, leaving a plume
of air in their wake, and before the bugs get to the chest, daring surgery
must be performed. Not only do we need to amputate his entire arm, the
collarbone and shoulder blade must also be removed, a so-called
“forequarter” amputation (as opposed to hindquarter, or lower limb).