A seemingly superficial injury escalated into a possibly life-threatening scenario when a patient arrived at BWH with an infected cut on his hand. Clinicians quickly deduced the infection had progressed into necrotizing fasciitis, colloquially known as “flesh-eating bacteria,” a rare but dangerous bacterial infection that can spread rapidly throughout the body.
Brandon Earp, MD, of BWH’s Department of Orthopaedic Surgery and chief of BWFH’s Department of Orthopedic Surgery, recently presented the case in The New England Journal of Medicine’s “Clinical Problem-Solving” feature, with co-authors Eileen Scully, MD, PhD, formerly of BWH’s Division of Infectious Disease; Amy Miller, MD, PhD, chief medical information officer of Inpatient Clinical Services; and Joseph Loscalzo, MD, PhD, MA, chair of the Department of Medicine and physician-in-chief.
The article, “Just a Cut,” guides readers through the case in a series of observations and explanations, alternating paragraphs of clinical narrative with in-the-moment analysis of care decisions made at each stage. In this Q&A with BWH Clinical & Research News, Earp explains why and how the team shared the case this way.
Why did you decide to present the case in this format?
Brandon Earp: If there’s an unusual case, we’ll frequently write an article about it and present it as a case report, but we decided to do this one a bit differently. The New England Journal of Medicine has a case method in which you tell the story as it progresses, with questions that come up along the way. It feels like it’s happening in real time, so it allows the reader to be there and think, ‘At this step, what’s going on? What questions should I ask?’
We thought presenting this case in that format was a really good way for providers to learn more about this clinical condition and the problem-solving process we went through.
How quickly did this case unfold?
Earp: From the time of injury, it was probably less than 12 hours before he was seen. He originally presented to his primary care provider, who was very astute and realized this was a significant problem, and personally walked him down to my clinic and said, ‘You need to see him right now.’
It was clear from the very moment I first saw him he was becoming systemically sick from this infection and needed emergent care. I had a very busy clinic that day, but those appointments unfortunately had to be canceled. That’s not something we do lightly, but this patient’s life was in danger; we needed to get him to the OR and drain the infection as quickly as possible.
How did you record your reactions to each step in the process?
Earp: Some of them were based on notes we took at the time, but most were reflections after the fact. The latter were not difficult to collect. Anytime you have a case where a patient has an extremely dangerous and challenging clinical condition, it impacts you as a provider, so you spend every waking moment thinking about how you’re going to help them and minimize the morbidity of his or her injury or illness.
As you thought about the problem-solving process, what lessons did you take away?
Earp: One of the things that I realized impacted me even more than the medical details of the case was how important it was that we worked as a team to take care of this patient – not only within Orthopaedics, but also with Infectious Disease doctors, hospitalists, rheumatologists, other care providers and even experts outside the Brigham.
Because the organism that caused the infection is quite rare in New England, we also contacted colleagues in southern locales who have more experience dealing with it – it is more prevalent in Florida and other warm-water areas. There isn’t a large pool of data that has been published about this organism, so when there’s limited data, you have to rely on wisdom.
Overall, we really pulled together to make joint decisions about the most appropriate way to manage this patient’s care every step of the way. It was clear to me as I was going through the writing process how vital this was – the Brigham shines when a situation is emergent and the team comes together.