4 ms·

The worst thing I saw in residency was a case of a 32 year old father of three who came presented with spontaneous pneumothorax. Chest tube was placed and he wa

by 303uru 3y ago

The worst thing I saw in residency was a case of a 32 year old father of three who came presented with spontaneous pneumothorax. Chest tube was placed and he was admitted, usually no big deal. Next morning the incision was slightly inflamed and he had some pain and mild fever. Later in the day he had follow up with pulmonary and he had black spots on the skin, pus, tachycardia, confusion. He was immediately taken to surgery and necrotizing fasciitis had already spread to his upper arm and a large portion of his chest. Arm and pectoral gone and he was placed into a hyperbaric chamber. 8 hours later no improvement, wheeled back to surgery, chest wall resection, lat removed, infection nearing hip. Back into hyperbaric. 8 hours later no improvement, hip and both legs gone, lobectomy and large section of neck had to be resected. 8 hours later and he was dead. Guy went from healthy, athletic actually, to a head connected to half a torso then dead in a day.

fatbird 3y ago
JFC. At no time did the doctors say "we can keeping cutting it away, but who wants to wake up like that?" After the second surgery, was there even a remote chance he'd survive?
- 303uru 3y ago
  In hindsight the decision is easy, at the time less so. The patient was making informed decisions alongside family but the speed and nature of necrotizing fasciitis make it very difficult. The skin can look largely fine until you begin surgery and find that the infection has spread 12 full inches along the fascia. So you cut that all out, plus some margin and hope for the best. There certainly was a chance he could have lived after the second surgery with a very altered life. And I get that, now that I have children I’d probably chose to live a very rough life just for a chance to watch them grow up. I truly can’t imagine what that man and his family went through in that short period of time. Decision making I slow decline with weeks or months is hard enough.
- haldujai 3y ago
  It is not up to physicians to decide whether the resulting quality of life reduction and morbidity from heroic interventions is worth it for a patient. If the intervention is unequivocally futile for preserving life it is permitted to not offer care, there are processes in place. While unlikely, it is possible to survive necrotizing fasciitis and multiple debridements. Although it will come with many months of reconstructions, rehabilitation and pain. We are legally and ethically obligated to offer heroic life saving measures if there is a chance of surviving. Quality of life is not a factor in our decision making process. I do not know the exact discussion was had with this patient and their decision maker when incapacitated but it would be extremely unusual for a previously healthy 32 year old to decline heroic interventions, this is also a very rapidly evolving infection where you don’t have much time to think. With that said I’ve also met 80+ year olds who want major surgeries that will leave them significantly impaired and almost certainly fail despite having time to think. At the end of the day patient autonomy supersedes our thoughts and opinions.
  - matheusmoreira 3y ago
    Completely agreed. I'd like to add to this part: > If the intervention is unequivocally futile for preserving life it is permitted to not offer care, there are processes in place. I want it to be clear that patients are not abandoned in these cases. Even in cases of serious incurable illnesses where death is imminent and cannot be prevented, there's plenty of things that can be done to provide comfort, manage symptoms and improve quality of life. Orthothanasia.
    - haldujai 3y ago
      Thank you for adding adding that. I should have phrased it as: “it is permitted to not offer the futile intervention / heroic measure.” As an example this is typically something like not offering CPR when death is imminent for another reason.
deleted 3y ago
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by 303uru 3y ago

fatbird 3y ago

JFC. At no time did the doctors say "we can keeping cutting it away, but who wants to wake up like that?" After the second surgery, was there even a remote chance he'd survive?

303uru 3y ago
In hindsight the decision is easy, at the time less so. The patient was making informed decisions alongside family but the speed and nature of necrotizing fasciitis make it very difficult. The skin can look largely fine until you begin surgery and find that the infection has spread 12 full inches along the fascia. So you cut that all out, plus some margin and hope for the best. There certainly was a chance he could have lived after the second surgery with a very altered life. And I get that, now that I have children I’d probably chose to live a very rough life just for a chance to watch them grow up. I truly can’t imagine what that man and his family went through in that short period of time. Decision making I slow decline with weeks or months is hard enough.
haldujai 3y ago
It is not up to physicians to decide whether the resulting quality of life reduction and morbidity from heroic interventions is worth it for a patient. If the intervention is unequivocally futile for preserving life it is permitted to not offer care, there are processes in place. While unlikely, it is possible to survive necrotizing fasciitis and multiple debridements. Although it will come with many months of reconstructions, rehabilitation and pain. We are legally and ethically obligated to offer heroic life saving measures if there is a chance of surviving. Quality of life is not a factor in our decision making process. I do not know the exact discussion was had with this patient and their decision maker when incapacitated but it would be extremely unusual for a previously healthy 32 year old to decline heroic interventions, this is also a very rapidly evolving infection where you don’t have much time to think. With that said I’ve also met 80+ year olds who want major surgeries that will leave them significantly impaired and almost certainly fail despite having time to think. At the end of the day patient autonomy supersedes our thoughts and opinions.
- matheusmoreira 3y ago
  Completely agreed. I'd like to add to this part: > If the intervention is unequivocally futile for preserving life it is permitted to not offer care, there are processes in place. I want it to be clear that patients are not abandoned in these cases. Even in cases of serious incurable illnesses where death is imminent and cannot be prevented, there's plenty of things that can be done to provide comfort, manage symptoms and improve quality of life. Orthothanasia.
  - haldujai 3y ago
    Thank you for adding adding that. I should have phrased it as: “it is permitted to not offer the futile intervention / heroic measure.” As an example this is typically something like not offering CPR when death is imminent for another reason.

deleted 3y ago

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