Critical Care Surgery Expert Witness Advises on Cases of Necrotizing Infections

Through my extensive experience as an acute and critical care surgeon, I’ve come to diagnose and treat numerous cases of necrotizing fasciitis/necrotizing soft tissue infection(NF/NSTI). Unfortunately this is a notoriously difficult diagnosis for the non-surgeon to make and its recognition is often delayed. Compounding the frequent delay in diagnosis is the fact that the single most important determinate of survival in NF/NSTI is the time it takes to get to the first surgical debridement and the extent of that debridement in the operating room. Delay in diagnosis and inadequate initial debridement are the two greatest pitfalls when encountering this difficult disease process.

Diagnosis

Necrotizing fasciitis/necrotizing soft tissue infection is a severe deep soft tissue infection that often spreads rapidly. It is often referred to in the lay media as “flesh eating bacteria”. Even when diagnosed and treated in a timely fashion, NF/NSTI still caries a high degree of morbidity and mortality. Therefore, the onus is on the physician to have a high degree of suspicion when encountering a possible diagnosis of NF/NSTI.

There is no one diagnostic tool that reliably diagnoses NF/NSTI. Rather, the entire clinical picture must be closely scrutinized by the physician. The physical exam remains the most important aspect of diagnosis. While fever is often absent, the presence of an elevated heart rate, elevated respiratory rate, and low blood pressure should raise alarms that the process may represent NF/NSTI rather than non-severe soft tissue infection. Furthermore, the infected site will often display pain out of proportion to the physical exam and the presence of bullae is an especially important diagnostic clue.

Laboratory tests in themselves are not diagnostic, but they do add additional data points to guide the diagnosis. The Laboratroy Risk Indicator for NF/NSTI (LRINEC) was developed to aid in the more timely diagnosis of NF/NSTI. It utilizes C-reactive protein, white blood cell count, hemoglobin, serum sodium, serum creatinine, and blood glucose as diagnostic aids. Similarly, imaging studies should only be considered as adjunctive measures to aid in the diagnosis of doubtful cases. Prompt surgical debridement should not be delayed for imaging if the overall clinical impression places NF/NSTI high on the differential diagnosis.

Treatment

Patients with suspected NF/NSTI should be treated immediately with empiric broad spectrum antibiotics covering gram positive, gram negative, and anaerobic organisms. Clindamycin is often administered as well in the case that the inciting organism produces the toxic shock protein. However, the mainstay of treatment is the rapid and aggressive surgical debridement of all suspect tissue. In fact, the initial surgery is the most important determinate of survival. Both with regards to the speed with which it is performed as well as to the extent of the debridement. There is a significant increase in mortality when surgery is delayed for even a few hours. Additionally, many patients require subsequent surgeries over the first several days in order to assure that all infected tissue has been removed.

What an Acute and Critical Care Surgery Expert Witness Can Help Determine

Perhaps the most important quality an acute and critical care surgery expert witness brings to a reviewing attorney within this category is the determinations of whether the treating physician displayed a high enough degree of suspicion to diagnosis this difficult and highly morbid disease process.

An acute and critical care surgery expert witness would review the extent and quality of the physical exam as well as all the adjunctive data. This includes laboratory tests and imaging studies that are necessary to diagnose NF/NSTI in a timely manner. Furthermore, most physicians who make the initial diagnosis of NF/NSTI are not surgeons. Critical care surgeon expert witness can determine whether appropriate and timely surgical consultations were obtained.

NF/NSTI is a surgical emergency and both the time to first debridement and the extent of that debridement are the most important determinates of survival. The acute and critical care surgeon expert witness would review the operative report and determine whether an appropriately aggressive debridement was performed and whether it was performed within an acceptable period of time.

NF/NSTI is a deadly disease process that appears to be increasing in frequency as the population of the U.S. ages and develops more chronic illness. Continuing to become more informed, as well as learning from and working with an acute and critical care surgery expert witness, will help all involved deal with the complicated topic.

This double board certified expert has been practicing for the past decade. Fellowship trained in Surgical Critical Care from one of the nation’s top medical schools, he holds membership in multiple prestigious medical societies and has been widely published in journals such as the Journal of Trauma and Acute Care Surgery and Surgical Clinics of North America. This American Association for the Surgery of Trauma Research and Education Scholarship Award Winner is currently an Assistant Professor of Surgery in the Division of Trauma and Critical Care at a major medical university.

Expert’s Bio: Location: Illinois B.A., Northwestern University M.D., University of Illinois College of Medicine Residency, General Surgery, Washington University in St. Louis Research Fellowship, Acute and Critical Care Surgery, Washington University in St. Louis Fellowship, Surgical Critical Care, Washington University in St. Louis Board Certified, American Board of Surgery Board Certified, American Board of Surgery – Surgical Critical Care Member, American College of Surgeons Member, Associate for Academic Surgery Member, Shock Society Member, Society of Critical Care Medicine Published, 20+ peer-reviewed articles, book chapters, and abstracts Current, Assistant Professor of Surgery, Division of Trauma and Critical Care, major medical university