Necrotising Fasciitis Case Study

We’ve been inspired to get up close and personal with the rather fancy sounding, but really rather yukky, Necrotising Fasciitis…

While largely linked to tropical climates, this condition can occur in other locations, so recognising it and knowing what to do as a first line of treatment is really important. We touched on Necrotising Fasciitis in this blog where the benefits of initial treatment with Betadine solution are discussed. In tropical climates, even tiny wounds can become necrotised and require ongoing debridement and cleaning, plus treating with oral and/or topical antibiotics. 

This article also grabbed our interest and demonstrates how quickly things can get severe out at sea. 

NOTE: you may only be able to view the article once!

A 57 year old male sailor (the patient) left Hawaii as Captain of a 37’ sailing vessel after competing in a race. He was accompanied by an 80+ year old and two novice sailors in their 20s and the destination was San Francisco. 

The patient had a history of chronic lymphocytic leukemia (a rare and slow developing form of cancer affecting the blood and bone marrow) and on the morning of departure he cut his right foot while walking on the beach. His underlying condition may have contributed to the infection due to the patient being immunocompromised.

Around 1-2 days after the injury, the patient noticed that it had become infected. Two days later and 600nm into the journey, the boat was hit by a rogue wave. The mainsail split and the boat’s communication equipment was damaged, though some communications were possible for a few more days until the only reliable communications possible was SMS messaging via Iridium GO!

What is Necrotising Fasciitis?

It’s also known as a ‘flesh-eating disease’ and while rare, it’s life threatening. It can develop in hours or as in this case, over a few days, but it needs urgent hospital treatment. 

The wound infection continued to worsen, and 7 days after departure, the boat’s telemedicine provider (George Washington Maritime Medical Access), contracted by the race organiser, was contacted during a window of good Iridium signal to initiate medical treatment. At this point, the pain score was just 3/10, the patient didn’t have a fever and there was no odour or pus. But pitting oedema, redness, darker discolouration and sloughing skin were present, along with serous fluid draining from the shin. 

A treatment plan of antibiotics and  wound dressing was recommended, but the medical kit did not contain anything other than a triple antibiotic ointment. Luckily another race competitor returning to the US was able to divert and deliver antibiotics. Communication continued to be a challenge for the patient’s vessel and the telemedicine provider had limited information about the patient's condition. 

Why are wound infections worse in a marine environment?

Along with normal skin flora, some marine bacteria are particularly aggressive, potentially fatal and require rapid treatment. With the added risks of injury onboard any boat, it’s advisable to carry antibiotics and other medications for skin and bacterial infections.

It took 2 days for the other vessel to rendezvous with the patient and the antibiotics were delivered safely. However the patient’s condition rapidly worsened that day. Pain score was now 7/10, the leg was swollen significantly and hot to touch from the knee down, he had a fever and the wound had developed draining pus and an odour. 

The decision to medevac the patient was made. However the remote location, outside of helicopter flying range, created an incredibly complex rescue. An oil and chemical tanker, the only large vessel in the vicinity was diverted to render aid, while a plan to fly out pararescuers to parachute in close to the patient was activated.

Transferring to the tanker from a sailboat was tricky and hampered by a language barrier. But the patient made it onboard by wrapping a line around himself and jumping, before being pulled onto a ladder then lifted onto the ship. Just 12 hours later the pararescue team were overhead and two rescuers parachuted into the ocean where they were picked up by the tanker's launch. A large swell and the sheer amount of medical kit they brought made this more hazardous than expected. 

Once with the patient, treatment started with pain relief, antibiotics and wound debridement. The team of two worked in round the clock shifts to care for the patient. It was decided that the time to surgical care should be minimised so the patient was airlifted to shore as soon as they were in range.  As per procedure, two helicopters are deployed in case one develops an issue. The patient and pararescuers were lifted onboard without issue and taken to a medical centre ashore. 

On arrival, the patient was stable, but with a large necrotic wound showing significant soft tissue damage, including gas pockets under the skin, typical of necrotising fasciitis. The wound was debrided over five surgeries that week and treated with antibiotics and wound VAC placement, where a specialised foam/gauze covers the wound to create a seal and a vacuum pump suctions fluid and debris from the wound to speed up healing.

The images below show the progression of the wound:

a) The last day on the sailing vessel

b) Two views on arrival at hospital

c) Healing

d) Skin graft after 2 weeks

e) Present day

We already know that longer voyages at sea mean increased medical risks for anyone onboard. So here are the key things to look out for if you suspect necrotising fasciitis:

• A wound that has broken the skin somewhere on the body due to a cut, scratch, burn, insect bite, surgery or injection.

• Intense pain or loss of feeling near to a cut or wound. The pain can seem much worse than you would usually expect.

• Swelling around the affected area.

• Flu-like symptoms - high temperature, headache, tiredness.

• Vomiting and diarrhoea.

• Confusion.

• Black, purple or grey blotches and blisters on the skin. This can be harder to identify on darker skin tones.

Ideally, make sure you make a good risk assessment of your medical needs and follow the mandatory guidance for your voyage and vessel. Clean and dress all wounds, no matter how small. Monitor at least daily for any signs of infection.

If you suspect that a wound is developing into necrotising fasciitis:

• Speak to your telemedicine provider in the first instance.

• If you have antibiotics onboard, you may be advised to administer them - they could be oral, intramuscular or intravenous..

• The patient will require an urgent medevac to hospital for antibiotics and surgery.

• Plan your route and transport to wherever the patient will be getting off the vessel - and follow the instructions from a helicopter if an airlift is required.