WEBVTT - Ep 193 Necrotizing Fasciitis: A strange beast 0:00:00.080 --> 0:00:02.360 My name is Maggie, and my story begins nearly two 0:00:02.440 --> 0:00:02.760 years ago. 0:00:02.759 --> 0:00:03.440 On New Year's Eve. 0:00:03.680 --> 0:00:05.640 My family went for a short hike in the woods 0:00:05.640 --> 0:00:07.960 that morning and then met some friends. 0:00:07.600 --> 0:00:09.440 To go bowling that evening. 0:00:09.480 --> 0:00:12.000 I thought maybe bowling had given me bresidas, as my 0:00:12.080 --> 0:00:15.720 elbow felt unusually painful. We went to bed long before 0:00:15.800 --> 0:00:18.400 ringing in the New Year, but the pain kept growing. 0:00:18.640 --> 0:00:20.599 I really wanted to sleep, so I made an ic 0:00:20.640 --> 0:00:23.400 sleeve out of a sock, but that pressure was too much, 0:00:23.440 --> 0:00:26.240 so I resorted to an old prescription pain med and 0:00:26.320 --> 0:00:29.840 waited impatiently for that to kick in before adding ibuprofento 0:00:29.840 --> 0:00:32.680 the mix. Soon after, my husband found me lying on 0:00:32.720 --> 0:00:35.240 our bedroom floor as I felt like I might pass out. 0:00:35.720 --> 0:00:37.800 He thought this was just my normal response to pain, 0:00:37.800 --> 0:00:40.720 because I have passed out in the pass But later 0:00:40.760 --> 0:00:44.200 I began vomiting, which I then attributed to taking meds 0:00:44.200 --> 0:00:45.080 on an empty stomach. 0:00:45.440 --> 0:00:47.000 By morning, I could not get out of bed. I 0:00:47.080 --> 0:00:47.640 was so sick. 0:00:48.040 --> 0:00:49.839 My husband kept trying to get me to stand so 0:00:49.840 --> 0:00:52.199 we could go to urgent care, but I couldn't. I 0:00:52.280 --> 0:00:54.640 finally felt a short window and we made it downstairs 0:00:54.720 --> 0:00:57.240 to the car and headed straight to the YAR instead. 0:00:58.120 --> 0:01:00.720 My husband wheeled me in with my bucket, and they 0:01:00.720 --> 0:01:04.080 found my blood pressure was considerably low. My normal resting 0:01:04.080 --> 0:01:06.600 heart rate of around sixty was elevated to ninety four 0:01:06.600 --> 0:01:10.720 beats per minute. I also coincidentally tested positive for COVID, 0:01:11.000 --> 0:01:13.199 so the er gave me my own room with full 0:01:13.240 --> 0:01:17.480 COVID precautions in place. On the second day, after multiple 0:01:17.480 --> 0:01:19.520 bags of ivy fluids that failed to bring up my 0:01:19.560 --> 0:01:22.640 blood pressure, they transferred me to the intensive care unit 0:01:22.680 --> 0:01:25.680 to treat me for septic shock. It's worth noting that 0:01:25.800 --> 0:01:27.640 three to four days prior to all this, I had 0:01:27.680 --> 0:01:31.400 visited my general practitioner for a lingering cold or sinus infection, 0:01:32.200 --> 0:01:35.360 and I was about three days into a prednizone prescription 0:01:35.840 --> 0:01:38.640 to calm down my inflammation. I was feeling good, but 0:01:38.680 --> 0:01:41.840 my immune system had clearly seen better days. This whole time, 0:01:41.880 --> 0:01:44.720 my arm had a noticeable redness that radiated from my elbow, 0:01:44.959 --> 0:01:45.360 and it was. 0:01:45.319 --> 0:01:46.199 Growing by the hour. 0:01:46.720 --> 0:01:49.280 Doctors were tracking the spread with sharpies, and there was 0:01:49.280 --> 0:01:52.600 a lot of discussion about whether to operate. My amazing 0:01:52.640 --> 0:01:55.360 infectious disease doctor was pushing for this to happen. I 0:01:55.360 --> 0:01:57.680 could hear my own voice telling my students how this 0:01:57.680 --> 0:02:00.160 can happen to anyone, but I could not believe that 0:02:00.240 --> 0:02:03.480 I was now that person. I remember trying to mentally 0:02:03.480 --> 0:02:06.280 prepare myself to give permission to amputate my arms should 0:02:06.280 --> 0:02:09.520 it become necessary to save my life. As the pain 0:02:09.560 --> 0:02:11.920 of redness approached my arm pit and shoulder, they found 0:02:11.919 --> 0:02:14.799 a surgeon that agreed to perform a debreedment of my arm. 0:02:15.400 --> 0:02:17.280 They opened me up with four long. 0:02:17.040 --> 0:02:20.840 Incisions that averaged three to four inches apiece, and after 0:02:20.880 --> 0:02:24.079 surgery they were wide open with all my deep tissues 0:02:24.080 --> 0:02:27.560 on full display. My dad was sent a picture and 0:02:27.600 --> 0:02:29.920 he passed out behind the wheel just thinking about it. 0:02:30.560 --> 0:02:33.560 He survived, his car did not, And it's pretty clear 0:02:33.600 --> 0:02:37.760 where I get my vasovagal response. My left arm had 0:02:37.919 --> 0:02:41.120 undergone so many blood draws and ivs that I developed 0:02:41.160 --> 0:02:43.800 a painful clot, forcing doctors to put in a central 0:02:43.840 --> 0:02:46.600 line to continue my meds. I was on at least 0:02:46.639 --> 0:02:48.920 three different antibiotics, and now I had to worry about 0:02:48.919 --> 0:02:51.080 the risk of a new infection going straight to my heart, 0:02:51.280 --> 0:02:54.440 as any catheter comes with the risk of infection. My 0:02:54.520 --> 0:02:57.280 most unpleasant memories, though, were the nights I insisted my 0:02:57.280 --> 0:02:59.200 family go home to sleep at night to stay strong 0:02:59.240 --> 0:03:02.040 and healthy. But many nights I cried myself to sleep, 0:03:02.120 --> 0:03:04.280 terrified I could not turn in my bed, and the 0:03:04.320 --> 0:03:06.760 morphine drip gave me startling dreams that would waken me. 0:03:07.400 --> 0:03:09.120 It was one of those nights I sent an email 0:03:09.160 --> 0:03:11.200 to the Errands asking them to save me a spot 0:03:11.200 --> 0:03:13.520 for when I beat this infection. I had made the 0:03:13.560 --> 0:03:17.720 mistake of reading the dire statistics for my condition online, 0:03:17.760 --> 0:03:18.920 and I was not about. 0:03:18.639 --> 0:03:20.800 To leave my six year old son or my husband behind. 0:03:21.800 --> 0:03:25.560 In the end, I had three surgeries, including another where 0:03:25.600 --> 0:03:28.359 they placed a wound back on my elbow and another 0:03:28.440 --> 0:03:31.079 to insert a wound drain and staple my arm closed. 0:03:31.720 --> 0:03:34.120 I was in the hospital for nearly nine days. I 0:03:34.160 --> 0:03:37.400 went in with suspected versidas, but the list of itises 0:03:37.480 --> 0:03:42.760 kept growing. I had cellulitis, toxic shock, sepsis, septic shock, 0:03:43.080 --> 0:03:47.600 and necrotizing fasciitis. The culture confirmed the infection was caused 0:03:47.600 --> 0:03:50.240 by group A strip. I was sent home with ivy 0:03:50.240 --> 0:03:52.440 penicillin through a pickline in my left arm while the 0:03:52.440 --> 0:03:55.840 wound drain hung from my right arm. I felt a 0:03:55.880 --> 0:03:58.000 bit like Pinocchio with so many strings but I was 0:03:58.040 --> 0:03:58.960 grateful to be home. 0:03:59.440 --> 0:04:01.560 I was very fortunate throughout all of this to have 0:04:01.600 --> 0:04:02.440 such great support. 0:04:02.720 --> 0:04:05.320 I'm grateful to my husband and my sisters, my care team, 0:04:05.400 --> 0:04:07.440 and all the friends and family who supported us through 0:04:07.480 --> 0:04:08.200 the scary time. 0:04:08.680 --> 0:04:10.640 We felt so loved and we hoped to never have 0:04:10.680 --> 0:04:12.280 to experience love in this way again. 0:04:58.320 --> 0:05:03.640 Oh my gosh, that is I mean, it's so it's terrifying, terrified. 0:05:04.480 --> 0:05:08.520 Oh oh, we're really glad that you're okay, and we 0:05:08.880 --> 0:05:12.600 appreciate you so much for being willing to share your story, 0:05:12.720 --> 0:05:14.360 that scary, scary story. 0:05:14.440 --> 0:05:16.600 Yeah, yeah, thank you, thank you so much. 0:05:17.120 --> 0:05:20.640 Yeah. Hi, I'm Aaron Welsh. 0:05:19.920 --> 0:05:21.600 And I'm Erin aman Updyke. 0:05:21.360 --> 0:05:23.400 And this is this podcast will Kill You. 0:05:23.960 --> 0:05:28.240 And today we're talking tissue death because we're covering necritizing 0:05:28.279 --> 0:05:29.120 fasci itis. 0:05:30.240 --> 0:05:34.240 We've covered as I was doing the history much of 0:05:34.440 --> 0:05:37.720 this in other capacities. I mean, this is a strange 0:05:37.760 --> 0:05:43.440 beast of a thing, right, Like enough said, Okay. 0:05:43.600 --> 0:05:50.479 Said, I agree, because we're talking like multiple bacterial species 0:05:51.120 --> 0:05:51.839 or groups. 0:05:52.640 --> 0:05:56.160 But there are so many questions that I have, and 0:05:56.240 --> 0:05:58.800 so I really just want to like go straight to things. 0:05:58.839 --> 0:06:01.679 So let's just get through the rest this business quickly. 0:06:01.839 --> 0:06:05.080 Yeah sounds good. First, it's quarantin any. 0:06:04.960 --> 0:06:08.080 Time it is it is. What are we drinking this week? 0:06:08.279 --> 0:06:13.840 We're drinking hit the gas Aaron. It was gas made like. 0:06:14.160 --> 0:06:16.080 It's one of those where you have to explain it, 0:06:16.120 --> 0:06:18.159 but it works on so many levels once you do. 0:06:19.800 --> 0:06:25.080 Gas means group a strap, but it also means gas 0:06:25.120 --> 0:06:28.520 as in air bubbles, which you might see on imaging 0:06:29.160 --> 0:06:34.279 if you have an advertizing soft tissue infection and anyways. 0:06:34.080 --> 0:06:37.719 In keeping in line with the gas air bubbles, of course, 0:06:37.800 --> 0:06:41.679 our drink is a well our plusy berita this week 0:06:41.800 --> 0:06:47.440 is a club soda plus BlackBerry syrup plus lemon juice. 0:06:48.520 --> 0:06:51.160 There you go. We did it, guys, we did it. 0:06:52.600 --> 0:06:54.880 We'll post it on our website. We're going to try 0:06:54.880 --> 0:06:57.920 to plus definitely social media. We will be posting it there, 0:06:57.960 --> 0:07:00.880 so make sure you're following us. We're also on YouTube, 0:07:00.920 --> 0:07:03.440 so make sure you're subscribed and all of that to 0:07:03.520 --> 0:07:06.720 the exactly right media YouTube channel. We have a website 0:07:06.720 --> 0:07:09.440 where you can find all sorts of things like transcripts 0:07:09.960 --> 0:07:14.440 like our submit your first hand account, form, a Goodreads list, bookshop, 0:07:14.640 --> 0:07:18.040 dot org, affiliate page, sources for each and every one 0:07:18.080 --> 0:07:23.240 of our episodes, music by Bloodmobile and some more goodies. 0:07:23.280 --> 0:07:24.080 So check it out. 0:07:24.600 --> 0:07:26.480 This podcast will kill you dot Com? Great? 0:07:27.240 --> 0:07:28.680 Great shall we? We shall? 0:07:29.120 --> 0:07:30.720 Okay right after this break. 0:07:45.360 --> 0:07:48.240 In some ways, Aaron, I think of necrotizing fasci itis 0:07:48.280 --> 0:07:49.680 as like an old friend of the pod. 0:07:50.680 --> 0:07:52.560 Yeah, I think that's fair to say, thank you. 0:07:52.640 --> 0:07:53.160 I'm glad you. 0:07:53.240 --> 0:07:56.960 I'm glad you agree, because we have covered so many 0:07:57.240 --> 0:08:03.360 of the major causes of necrotizing fasciitis classically, the primary 0:08:03.400 --> 0:08:06.720 agent that we think of within necrotizing fasciadis infection is 0:08:06.760 --> 0:08:11.160 a beta heat meltic streptococcie called strap piogenies aka group 0:08:11.160 --> 0:08:14.800 A strap aka the cause of scarlet fever, among many 0:08:14.840 --> 0:08:15.640 other things. 0:08:15.520 --> 0:08:19.280 Which we have done exactly We've done that. We've also done. 0:08:19.520 --> 0:08:25.400 Yeah, we've also done toxic shock very recently, which necrotizing 0:08:25.400 --> 0:08:31.400 fasciitis often leads to a toxic shock syndrome. Necrotizing fasciidis 0:08:31.440 --> 0:08:34.520 also can often lead to sepsis, which we've also covered. 0:08:35.800 --> 0:08:38.840 I mean, I think this just goes to show if 0:08:38.920 --> 0:08:41.080 I may be a little not like philosophical, but I 0:08:41.080 --> 0:08:44.640 guess like historical. You know, back when germ theory was 0:08:45.000 --> 0:08:47.920 the newest thing of the day, and it was suddenly 0:08:47.960 --> 0:08:51.600 like every disease is one germ, right, like each disease 0:08:51.640 --> 0:08:54.640 has one germ kind of a thing. And this disrupts 0:08:54.720 --> 0:09:00.240 that paradigm on which I find so interesting because are 0:09:00.480 --> 0:09:04.319 the way that we approach this podcast is very much 0:09:05.000 --> 0:09:07.320 one disease, one thing. 0:09:07.840 --> 0:09:09.760 Well, and it's interesting too, and we've talked about this. 0:09:09.800 --> 0:09:12.240 I wish I could remember on what episode it was, 0:09:12.320 --> 0:09:15.720 because you have both, right, you have sometimes like one 0:09:15.760 --> 0:09:18.920 pathogen that can cause so many different types of disease, 0:09:19.000 --> 0:09:22.840 like with MRSA, like with streptococcus, but then you also 0:09:22.960 --> 0:09:27.480 have one disease or one clinical syndrome like necrotizing fasciitis, 0:09:27.559 --> 0:09:31.120 that can be caused by so many different pathogens because 0:09:31.120 --> 0:09:35.600 it isn't just group A strip no no. Necrotizing fasciitis. 0:09:35.640 --> 0:09:37.959 Infections can also be caused by another good friend of 0:09:37.960 --> 0:09:43.439 the pod, Staphlococcus aureus, including MRSA or methicillin resistant Staph oureus. 0:09:43.840 --> 0:09:48.720 It can also be caused by clusterdium species by Vibrio vulnificus, 0:09:48.720 --> 0:09:50.560 which we haven't yet covered. 0:09:50.200 --> 0:09:51.600 And we should we should. 0:09:52.120 --> 0:09:56.400 Vibrio is a marine or aquatic bacterium that can cause 0:09:56.440 --> 0:10:00.160 a neckritizing infection, especially after injuries, so like you get 0:10:00.280 --> 0:10:03.320 you know, nicked while you're fishing, or a fish scale 0:10:03.400 --> 0:10:06.000 kind of scratches you, or you just go swimming when 0:10:06.080 --> 0:10:09.800 you have a bug bite or a scratch. Anyways, but 0:10:10.000 --> 0:10:14.440 there also are a whole bunch of necrotizing fasci idis 0:10:14.440 --> 0:10:18.760 infections that are actually polymicrobial, and these can include both 0:10:18.880 --> 0:10:22.360 gram negative and gram positive bacterium so friends like E. 0:10:22.480 --> 0:10:25.160 Coli or Clipsiella in addition to all of the things 0:10:25.200 --> 0:10:30.040 that we've already described. So whatever the organism in question, 0:10:30.600 --> 0:10:34.319 what is necrotizing fasci i itis you mean? Yeah, I've 0:10:34.360 --> 0:10:37.400 said the words so many times now. It is a 0:10:37.440 --> 0:10:43.640 severe bacterial infection that starts in the skin usually and 0:10:43.760 --> 0:10:48.920 spreads down deep through the layers, through the dermis, through 0:10:48.960 --> 0:10:53.920 the subcutaneous fat, and into a layer called the fascia. 0:10:54.040 --> 0:10:55.920 And I want to spend a moment to talk about 0:10:55.960 --> 0:10:59.480 our fascia. Okay, great, We have a lot of different 0:10:59.520 --> 0:11:03.000 types of fashia in our bodies. It is basically a 0:11:03.200 --> 0:11:08.440 part of our connective tissue network. Our fascia layers give 0:11:08.720 --> 0:11:12.920 support to various structures in our body, so just underneath 0:11:12.920 --> 0:11:15.680 our if you think, I'm using my finger as an example, 0:11:16.000 --> 0:11:17.560 So if you think of looking at the palm of 0:11:17.559 --> 0:11:21.080 your hand, the top of your finger being your skin, 0:11:21.520 --> 0:11:23.720 You've got your epidermis and dermis, and then you have 0:11:23.800 --> 0:11:26.960 a layer. Then you've got your subcutaneous tissue like under 0:11:27.000 --> 0:11:30.040 your first knuckle, okay, and then just under that you're 0:11:30.040 --> 0:11:32.520 going to have a layer like under your second knuckle 0:11:32.559 --> 0:11:36.760 here of superficial fascia and then a layer of deep 0:11:36.800 --> 0:11:38.040 fascia and then muscle. 0:11:39.120 --> 0:11:41.880 What's the purposes of superficial and deep fascia. 0:11:42.320 --> 0:11:45.479 They're all there to support our structure. So the superficial 0:11:45.480 --> 0:11:48.920 fascia is like the underlayer underneath our skin. The deep 0:11:48.960 --> 0:11:51.520 fascia is what surrounds our muscles, So all of our 0:11:51.600 --> 0:11:54.680 muscles are covered in their own layer of fascia. Our 0:11:54.880 --> 0:11:57.920 organs inside of our body also have their own versions 0:11:57.920 --> 0:12:01.160 of fascia, and then our body cavi these have their 0:12:01.200 --> 0:12:04.320 own layer of fascia as well, our abdominal wall and 0:12:04.320 --> 0:12:07.439 our thoracic cavity. So we've got layers upon layers upon 0:12:07.520 --> 0:12:08.439 layers of fascia. 0:12:08.840 --> 0:12:10.080 What's fascia made of? 0:12:10.720 --> 0:12:14.600 Mostly collagen. Oh okay, Yeah, it's mostly collagen. And when 0:12:14.640 --> 0:12:16.839 you look at it, it usually looks like a kind 0:12:16.880 --> 0:12:20.680 of white, kind of filamentous. 0:12:19.600 --> 0:12:23.640 Sort of structure, almost like I don't know a. 0:12:23.520 --> 0:12:27.720 Good example, like angel hair, spaghetti. 0:12:28.240 --> 0:12:30.880 No, it's more like like. 0:12:30.960 --> 0:12:34.360 Insulation and your wall quite the inside of an orange peel, 0:12:34.440 --> 0:12:41.600 because it's stringier than that, like. 0:12:39.360 --> 0:12:42.120 Like fungal growth in the last of us. 0:12:42.600 --> 0:12:45.920 Yeah, except imagine it being quite firm, you know, like 0:12:46.040 --> 0:12:48.000 like really tough spider web. 0:12:48.400 --> 0:12:49.920 Okay, like you know those. 0:12:49.760 --> 0:12:52.959 Like cellulose shades that you sometimes can have on your 0:12:53.040 --> 0:12:55.760 cover your window where like the sun can't get in 0:12:55.800 --> 0:12:57.480 but you can still kind of see out or whatever, 0:12:57.559 --> 0:12:59.960 or the sun can get in but they can't like that. Okay, 0:13:00.200 --> 0:13:02.920 not quite opaque. And anyways, that was a struggle. I 0:13:02.920 --> 0:13:05.240 probably should have thought of it before I started talking. 0:13:07.760 --> 0:13:11.040 Had a really fun time guessing guessing things that I 0:13:11.040 --> 0:13:13.280 have no idea what the actual image of it. 0:13:13.120 --> 0:13:18.000 Is, especially based on my hand motions, which are entirely unhelpful. Anyways, 0:13:18.480 --> 0:13:21.320 So we're talking about a bacterial infection that spreads down 0:13:21.480 --> 0:13:24.880 into this layer, and which layer of fashion just depends 0:13:24.920 --> 0:13:29.079 on how far the infection goes. But as this infection spreads, 0:13:29.120 --> 0:13:33.480 what makes it a necrotizing infection is that the bacteria 0:13:33.640 --> 0:13:38.040 start to produce various toxins, which one which type. It's 0:13:38.120 --> 0:13:40.600 all going to depend on what the pathogen is, because 0:13:40.600 --> 0:13:44.440 there can be so many, but many of the types, 0:13:44.480 --> 0:13:46.600 and sometimes it's not even toxic. Media is more just 0:13:46.640 --> 0:13:50.200 like this overwhelming bacterial infection. But in any case, whether 0:13:50.240 --> 0:13:53.320 it's toxin mediated or just from so many bacteria, we 0:13:53.400 --> 0:13:57.360 see a lot of inflammatory damage, including in the blood 0:13:57.440 --> 0:14:01.560 vessels of our tissues that ends up leading to blood 0:14:01.640 --> 0:14:06.720 clots so called microthrombi, and that caused death necrosis of 0:14:06.760 --> 0:14:12.120 the tissue itself. Now, the term necrotizing fasciitis, that's what 0:14:12.120 --> 0:14:16.000 we're using in this. It's not an incorrect term, but 0:14:16.920 --> 0:14:19.360 what we have come to learn is that there are 0:14:19.640 --> 0:14:23.440 a lot of other kinds of necrotizing soft tissue infections. 0:14:23.840 --> 0:14:26.960 So an umbrella term that's often used now is NSTI 0:14:27.160 --> 0:14:31.280 necrotizing soft tissue infections. Some of them get their own name, 0:14:31.440 --> 0:14:34.480 Like if it's only in the skin and subcutaneous fat, 0:14:34.520 --> 0:14:37.360 you can have a necrotizing cellulitis and that would be 0:14:37.680 --> 0:14:40.680 less deep, not all the way down to the fascia. 0:14:40.760 --> 0:14:43.440 If it's all the way to the muscle or primarily 0:14:43.520 --> 0:14:46.080 in the muscle, this might start from a muscle injury 0:14:46.160 --> 0:14:48.240 rather than like a skin damage. You can get a 0:14:48.280 --> 0:14:53.320 piomocitis or a myonecrosis. Myonecrosis is what we see with 0:14:53.400 --> 0:14:56.440 gas ganggreen, which is caused by a type of clustered 0:14:56.480 --> 0:15:00.680 am species. Yes, but these are not all mutually exclusive. 0:15:01.280 --> 0:15:05.560 But the reason that neckartizing fasci itis itself kind of 0:15:06.000 --> 0:15:08.720 I think holds a lot of esteem. I don't know 0:15:08.760 --> 0:15:10.280 if esteem is the right word, but that is like 0:15:10.360 --> 0:15:12.080 the one that we think of when we think of 0:15:12.120 --> 0:15:15.440 a necrotizing soft tissue. Infection is in part because it's 0:15:15.480 --> 0:15:18.320 the most common, and the reason that it's most common 0:15:18.480 --> 0:15:22.440 is because the fascia has some components to it that 0:15:22.520 --> 0:15:27.160 make it particularly vulnerable to infection. First of all, the 0:15:27.200 --> 0:15:30.320 blood supply to our fascia is not nearly as robust 0:15:30.520 --> 0:15:33.359 as the blood supply to our skin, to our subcutaneous 0:15:33.360 --> 0:15:36.240 tissue and to our muscle. It is just there for support, 0:15:36.680 --> 0:15:40.680 I see, and so it doesn't need usually as robust 0:15:40.680 --> 0:15:42.760 of a blood supply. It's not a muscle that's contracting, 0:15:42.880 --> 0:15:46.280 it's not our skin that's constantly regenerating. It's just there 0:15:46.400 --> 0:15:48.920 as like a you know, shingles on the outside of 0:15:48.920 --> 0:15:52.440 your house. That's a bad example. It's a sport structures, 0:15:52.600 --> 0:15:54.200 but it's not as support structure at all. 0:15:54.400 --> 0:15:55.040 That's your skin. 0:15:58.480 --> 0:16:01.800 I have a quick question about this infection. So you 0:16:01.840 --> 0:16:05.280 talk about it going deep, What is the it goes 0:16:05.320 --> 0:16:08.160 deep and wide? Right, Like, Yeah, what does it do 0:16:08.440 --> 0:16:11.040 first and in what order and at what rates? 0:16:11.440 --> 0:16:14.880 That is another component of the fascia itself that makes 0:16:14.960 --> 0:16:18.880 it so vulnerable to these type of infections because once 0:16:18.920 --> 0:16:23.320 an infection gets into that fascial plane, it can spread 0:16:23.520 --> 0:16:27.040 along that fascial plane without interacting with any of the 0:16:27.080 --> 0:16:32.080 other tissue areas. Oh so once it gets into that fascia, 0:16:32.120 --> 0:16:34.320 think of it like a highway. Now it's just on 0:16:34.480 --> 0:16:38.480 this freeway, no stops needed, and so little blood supply 0:16:38.560 --> 0:16:40.320 that there's not a lot of things coming in to 0:16:40.440 --> 0:16:44.280 carry off or to fight that infection. So, yes, it 0:16:44.360 --> 0:16:49.120 is something that spreads widely, very quickly, and oftentimes the 0:16:49.280 --> 0:16:53.400 first like where that infection first started, it can't. Most 0:16:53.440 --> 0:16:56.840 often it starts from something like a scratch on the skin. Yeah, 0:16:56.920 --> 0:16:58.240 it can be a small wound it can be a 0:16:58.320 --> 0:17:01.720 large wound, it could be a surgical wound. But it 0:17:01.840 --> 0:17:05.760 sometimes isn't even like a known wound to the skin. 0:17:05.880 --> 0:17:09.640 Sometimes it's damaged to like the muscle itself. Right, you 0:17:09.840 --> 0:17:12.640 injure your muscle, you hid it something like that, and 0:17:12.800 --> 0:17:15.680 there you have, for some reason bacteria that made it 0:17:16.000 --> 0:17:20.399 from your bloodstream into that fascil plane. How you know, 0:17:21.000 --> 0:17:23.359 because so many of these bacteria that tend to cause 0:17:23.359 --> 0:17:25.520 this infection live on our skin all the time, right, 0:17:25.720 --> 0:17:29.600 Like Streptococcus can live Staphylococcus can just live on us. 0:17:29.960 --> 0:17:33.600 And so some people every once in a while might 0:17:33.720 --> 0:17:36.959 have some bacteria that make their way into our bloodstream 0:17:37.080 --> 0:17:39.360 and then our body manages to fight them off. Most 0:17:39.359 --> 0:17:42.760 of the time, it's what we call transient bacteremia. Most 0:17:42.760 --> 0:17:44.520 of the time you might never know that that happens. 0:17:46.040 --> 0:17:48.600 But if that happens and you have an injury and 0:17:48.720 --> 0:17:51.520 these bacteria happen to make it into this fascia, they 0:17:51.520 --> 0:17:54.080 could potentially establish an infection. And to be honest, we 0:17:54.080 --> 0:17:57.439 don't fully understand like why and who on all of that, Okay, 0:17:58.000 --> 0:18:00.719 but once it's there, it can very quickly kind of 0:18:00.880 --> 0:18:07.040 spread along this fascial plane without necessarily causing more visible damage. Right, 0:18:07.080 --> 0:18:09.680 you might not see damage to the skin because it's 0:18:09.680 --> 0:18:13.200 mostly tracking along the fascia. And the final thing about 0:18:13.200 --> 0:18:15.840 the fascia that can make this particularly vulnerable is that 0:18:16.200 --> 0:18:20.840 because I'm talking about like distinct layers of tissue, there's 0:18:20.960 --> 0:18:23.800 kind of this what we call a potential space that exists, 0:18:24.080 --> 0:18:26.840 like think of it as like between these layers of tissue. 0:18:26.880 --> 0:18:27.880 So what part of what. 0:18:27.800 --> 0:18:32.040 The fashia does is allow for things to slide against themselves, right, 0:18:32.119 --> 0:18:35.360 Like it provides support, but it also allows your muscles 0:18:35.400 --> 0:18:38.600 to slide against a smooth surface. What that means is 0:18:38.640 --> 0:18:42.520 that there is a like theoretical space microscopic though it 0:18:42.520 --> 0:18:47.160 may be between these tissue layers. That space can fill 0:18:47.240 --> 0:18:50.920 with fluid, and it does in a necrotizing infection, and 0:18:50.960 --> 0:18:54.399 that fluid can make it even harder for our body 0:18:54.440 --> 0:18:57.320 to respond and clear that infection because our immune cells 0:18:57.359 --> 0:18:59.440 have to like wade through a swimming pool of fluid 0:18:59.480 --> 0:19:01.360 to try and to this infection. 0:19:02.119 --> 0:19:10.480 Okay, Okay, so somehow bacteria invade the fascia. H The 0:19:10.640 --> 0:19:14.720 fascia dies fairly easily because there's once it erodes the 0:19:14.720 --> 0:19:17.639 blood supply there's not a lot of redundancy and so 0:19:17.880 --> 0:19:21.680 there's no more like you said, highway. So then once 0:19:21.720 --> 0:19:25.160 it goes under like along the rest of the fascia, 0:19:25.240 --> 0:19:28.880 then the tissue on top of that will just sort 0:19:28.920 --> 0:19:30.320 of die. 0:19:30.480 --> 0:19:32.160 It can or it cannot. 0:19:32.320 --> 0:19:36.320 So sometime like eventually this infection will get so overwhelming 0:19:36.359 --> 0:19:39.560 that it will continue to invade, So it'll either invade 0:19:39.600 --> 0:19:42.800 down into the muscle or it will invade continue going 0:19:42.880 --> 0:19:45.840 like back up and out back towards the skin, and 0:19:45.880 --> 0:19:48.119 then you'll see more evidence of the damage on the skin. 0:19:48.440 --> 0:19:52.320 Okay, can we talk about the bacteria involved and what 0:19:52.520 --> 0:19:57.160 makes them more likely or toxins or the differences between them, 0:19:57.240 --> 0:19:58.959 like why why does this happen? 0:19:59.480 --> 0:20:02.200 Yeah, it's it's a great question, and that because that's 0:20:02.240 --> 0:20:05.360 a it's a multi part question, right, because it's why 0:20:05.359 --> 0:20:08.080 does this happen to certain people? Why does this happen 0:20:08.080 --> 0:20:11.639 in certain situations? And why does this happen from certain bacteria? 0:20:12.200 --> 0:20:14.040 Yeah, and that's a lot. 0:20:14.040 --> 0:20:15.480 I don't think I'm gonna have answers for all of 0:20:15.480 --> 0:20:22.439 this questions. We know from episodes that we've done on 0:20:22.520 --> 0:20:25.680 group A strep in the past, as well as from 0:20:25.720 --> 0:20:29.800 Staphylococcus aureus. These are two bacteria that produce a lot 0:20:29.840 --> 0:20:34.480 of exotoxins. These toxins produce a really robust and strong 0:20:34.520 --> 0:20:38.520 inflammatory response in us, and that inflammation can cause damage. 0:20:40.080 --> 0:20:43.040 Vibrio vugnificence. I didn't actually dig deep into it. I 0:20:43.080 --> 0:20:44.840 just know that it is quite virulent and I'm not 0:20:44.880 --> 0:20:46.879 exactly sure what all of its virillance factors are. 0:20:47.080 --> 0:20:48.719 Just means you need to do a full episode on it. 0:20:49.680 --> 0:20:53.840 And then Clostridium is also like a toxin mediated infection, 0:20:53.960 --> 0:20:57.280 So it's again this toxin and an inflammatory response because 0:20:57.320 --> 0:20:57.960 of that toxin. 0:20:58.720 --> 0:21:01.639 Are these the same toxins or different toxins? Is the 0:21:01.680 --> 0:21:05.160 mechanism of action different of different kinds? Yeah, a ton 0:21:05.200 --> 0:21:07.800 of different kinds, And a lot of these infections are 0:21:07.800 --> 0:21:13.360 actually polymicrobial. So another big component is that there are 0:21:13.840 --> 0:21:17.320 certain risk factors to who is more likely to get 0:21:17.320 --> 0:21:22.360 and what scenarios are more likely to get necrotizing infection. Right, 0:21:22.440 --> 0:21:26.520 so individual level factors things like diabetes, cirrhosis or other 0:21:26.560 --> 0:21:32.080 liver disease, certain compromising conditions, and the elderly are the 0:21:32.119 --> 0:21:36.000 most high at risk for a necritizing skin and soft 0:21:36.000 --> 0:21:41.760 tissue infection. Things that are environmental, like fishing in waters 0:21:41.880 --> 0:21:45.560 that are contaminated with vibrio and having an open wound 0:21:45.880 --> 0:21:49.840 is going to environmentally put you at a higher risk. Right, 0:21:50.200 --> 0:21:51.760 how is viio transmitted? 0:21:52.400 --> 0:21:54.760 It just gets into your skin through these open wounds. 0:21:54.760 --> 0:21:56.320 Right, But I mean, like where is it coming from 0:21:56.320 --> 0:21:57.080 in the environment. 0:21:57.359 --> 0:22:00.000 It lives in the environment. It can thrive in the ocean. 0:22:00.200 --> 0:22:03.639 It's also can get to very high concentrations in filter 0:22:03.680 --> 0:22:06.840 feeders like shellfish like oysters. So you also can get 0:22:06.920 --> 0:22:10.800 quite a severe GI infection from eating raw oysters and 0:22:10.840 --> 0:22:12.080 things because of embrya. 0:22:12.440 --> 0:22:16.760 So it's not like our residence no staph and. 0:22:16.760 --> 0:22:20.240 Okay, correct, Yeah, this one is like specifically environmental, whereas yeah, 0:22:20.280 --> 0:22:23.520 most of the rest of these even E Coli, clubziella, 0:22:23.680 --> 0:22:26.359 these are things that just live in us and on us. 0:22:27.040 --> 0:22:30.119 And so really it's just about the wrong time and 0:22:30.200 --> 0:22:34.720 the right port of entry that contribute to someone eventually 0:22:34.760 --> 0:22:39.919 getting a necritizing infection. In terms of what it looks like. 0:22:41.160 --> 0:22:44.040 The scariest thing, there's a lot of scary things about 0:22:44.200 --> 0:22:47.760 neckritizing fasci itis. One of the scariest things is that 0:22:47.920 --> 0:22:52.800 at first it is very hard to distinguish from a 0:22:52.880 --> 0:22:57.840 totally benign skin infection, So it can look very similar 0:22:57.840 --> 0:23:02.880 to things like arisipolis or there's like a few differences, 0:23:04.080 --> 0:23:07.159 but at the very beginning, there's not, like there's not 0:23:07.200 --> 0:23:09.840 a lot that necessarily distinguishes these early in the course 0:23:09.880 --> 0:23:14.280 of infection. And that's where the danger really lies when 0:23:14.280 --> 0:23:17.879 it comes to necritizing fasci idis, because the big difference 0:23:18.240 --> 0:23:23.439 is that it progresses incredibly rapidly compared to other skin infections, 0:23:24.040 --> 0:23:26.760 and by that I mean on a matter of hours 0:23:27.320 --> 0:23:31.120 or a couple of days rather than days to weeks 0:23:31.240 --> 0:23:34.000 that we might see the progression of a cellulitis turning 0:23:34.000 --> 0:23:37.640 into a lymphangitis streaking up your arm or an ariseplus 0:23:37.760 --> 0:23:39.560 turning into something that has you know, a lot of 0:23:39.640 --> 0:23:43.800 vesicles or blisters or things like that. So you can 0:23:43.920 --> 0:23:47.359 imagine the nightmare which I have seen, and it is 0:23:47.440 --> 0:23:51.640 truly a nightmare that someone comes into the emergency room 0:23:51.840 --> 0:23:55.720 with like a red spot on say their leg, or 0:23:55.760 --> 0:23:58.080 maybe even just kind of like a patchy area of 0:23:58.119 --> 0:24:02.639 like discoloration or a little bit of swelling. You're going 0:24:02.720 --> 0:24:04.320 to touch it or push on it to see if 0:24:04.359 --> 0:24:07.600 there's any in duration or sign of an absess and 0:24:07.680 --> 0:24:09.400 one of the signs they teach you to look out 0:24:09.440 --> 0:24:13.000 for in medical school is called pain out of proportion. 0:24:13.280 --> 0:24:17.000 If you touch a necrotizing infection, that person is practically 0:24:17.000 --> 0:24:18.720 going to jump off of the table because of how 0:24:18.720 --> 0:24:21.760 incredibly painful it is compared to what it looks like. 0:24:22.320 --> 0:24:23.320 Yes, okay. 0:24:24.080 --> 0:24:26.199 The other thing you can sometimes see early in the 0:24:26.240 --> 0:24:29.600 course of infection is that you might have swelling like 0:24:29.840 --> 0:24:33.439 edema that goes beyond the area of redness or of 0:24:33.480 --> 0:24:37.160 like a dark purplish discoloration, So you're like more swollen 0:24:37.320 --> 0:24:39.960 than this area that looks like it has an infection 0:24:40.480 --> 0:24:44.280 mm hmm. And then the signs that are like more 0:24:44.480 --> 0:24:48.399 classically associated with a neckritizing fasci iis tend to be 0:24:48.480 --> 0:24:51.400 pretty late stage signs, which means you might have missed 0:24:51.400 --> 0:24:54.199 a pretty critical window for intervention. But these are the 0:24:54.240 --> 0:24:56.480 things that you see a lot of pictures of online. 0:24:56.560 --> 0:24:57.160 These are like. 0:24:57.359 --> 0:25:00.679 Bullet or the really large flow you would filled or 0:25:00.720 --> 0:25:05.040 sometimes blood filled blisters. You get a lot of bruising 0:25:05.240 --> 0:25:07.920 of the skin, and you get that before you start 0:25:07.920 --> 0:25:11.000 to see tissue death like skin death or necrosis of 0:25:11.040 --> 0:25:14.680 the skin. If you do imaging, which we often do. 0:25:15.119 --> 0:25:17.359 It'll be a seed t scan or an MRI scan. 0:25:18.080 --> 0:25:21.600 You might see gas in the tissues, especially tracking along 0:25:21.720 --> 0:25:23.200 that fascion plane. 0:25:23.119 --> 0:25:24.440 Where's the gas coming from. 0:25:24.800 --> 0:25:26.920 The gas is coming from the bacteria itself. It's part 0:25:26.960 --> 0:25:28.080 of their metabolism. 0:25:28.160 --> 0:25:28.920 Yeah, what I thought. 0:25:29.720 --> 0:25:33.680 You also sometimes can see this without imaging by crepitence 0:25:34.040 --> 0:25:37.199 on exam, So that's that like rice crispy feeling and 0:25:37.280 --> 0:25:40.600 sound when you press on the skin when it gets 0:25:40.720 --> 0:25:42.840 very severe, instead of that pain out of proportion, you 0:25:42.920 --> 0:25:45.840 might actually have anesthesia cutaneous anesthesia where you don't even 0:25:45.840 --> 0:25:47.840 feel your skin at all because so much of those 0:25:47.920 --> 0:25:53.280 nerves have died without treatment. This will progress incredibly rapidly 0:25:54.560 --> 0:25:59.520 and will then include fever, hypotension, It can progress to 0:25:59.520 --> 0:26:02.760 toxic shit syndrome, it can progress to sepsis and shock 0:26:03.280 --> 0:26:08.000 and death. And really one of the hardest parts is 0:26:08.000 --> 0:26:13.560 that early diagnosis. The statistics, unfortunately are not great. The 0:26:13.600 --> 0:26:16.119 best ones I saw were that about fifty percent of 0:26:16.160 --> 0:26:19.600 the time necrotizing soft tissue infections are not diagnosed initially 0:26:19.600 --> 0:26:22.200 on an admission in the er. But I've seen other 0:26:22.240 --> 0:26:25.040 papers that said like eighty five to one hundred percent. 0:26:24.800 --> 0:26:28.159 Of the time, which it just seems actually bananas. 0:26:27.640 --> 0:26:33.439 But yeah, yeah, it's it's it's a really that's a 0:26:33.480 --> 0:26:37.760 really huge problem because the treatment for this is early 0:26:38.000 --> 0:26:42.920 surgical intervention, Okay, and by early I mean within twenty 0:26:42.920 --> 0:26:46.920 four hours of this diagnosis, and the earlier the better. 0:26:47.240 --> 0:26:49.680 So if if oars are set up to be there 0:26:49.680 --> 0:26:52.240 in a matter of hours, that person is more likely 0:26:52.240 --> 0:26:56.040 to have a better outcome than otherwise. The surgical degreement 0:26:56.080 --> 0:27:00.359 can be really extensive. The average number of surge that 0:27:00.359 --> 0:27:02.720 somebody needs after a necrotizing fasciitis is. 0:27:02.680 --> 0:27:03.399 Three to four. 0:27:05.119 --> 0:27:09.199 They sometimes require amputation depending on the location and the 0:27:09.280 --> 0:27:14.760 extent of that initial infection, and even if they don't 0:27:14.760 --> 0:27:19.520 require amputation, they often require such extensive debreedment of all 0:27:19.600 --> 0:27:23.160 of that dead tissue to be able to get down 0:27:23.200 --> 0:27:26.440 to healthy tissue that you are going to have an 0:27:26.440 --> 0:27:29.240 open wound for a very long time in order to 0:27:29.320 --> 0:27:32.600 allow healthy tissue to kind of heal back in while 0:27:32.640 --> 0:27:37.160 you're on antibiotics to fight off that infection. That may 0:27:37.200 --> 0:27:40.040 require packing changes, or it may require what's called a 0:27:40.080 --> 0:27:42.600 wound back, which keeps like negative pressure on the wound, 0:27:42.600 --> 0:27:46.280 which can be quite painful and cumbersome, and then very 0:27:46.320 --> 0:27:50.760 often people need skin graphs or complex reconstructive surgeries to 0:27:50.840 --> 0:27:53.040 be able to heal over time. So this is something 0:27:53.080 --> 0:27:56.360 that has like a pretty long lasting impact on somebody's 0:27:56.359 --> 0:27:58.000 life if they survive. 0:27:59.160 --> 0:28:05.360 Yeah, I know that necrotizing fasciitis. We have fascia all 0:28:05.400 --> 0:28:08.760 over our bodies, and so it can happen anywhere. Are 0:28:08.800 --> 0:28:11.439 there places that it's more likely to happen? 0:28:12.840 --> 0:28:15.720 Most likely places are the extremities. I think the legs, 0:28:15.760 --> 0:28:18.639 lower legs are the most likely, just because that is 0:28:18.680 --> 0:28:24.200 where you have so much potential for exposure to like wounds. 0:28:24.320 --> 0:28:27.040 Plus they're such a strong association with diabetes, and so 0:28:27.160 --> 0:28:29.320 diabetic foot wounds are a place that you can really 0:28:29.359 --> 0:28:31.040 easily get a necritizing infection. 0:28:31.800 --> 0:28:32.560 But there are a. 0:28:32.520 --> 0:28:37.879 Few places that have specific names associated with them because 0:28:37.920 --> 0:28:42.120 they have like a specific set of syndromes. So Fournier's 0:28:42.160 --> 0:28:47.000 ganggreen is a specific name for necrotizing fasciitis of the genitalia. Yeah, 0:28:47.040 --> 0:28:50.960 which can be really really horrific. Has a high mortality 0:28:51.000 --> 0:28:54.800 rate and just a huge amount of morbidity associated with it. 0:28:54.800 --> 0:28:59.560 It's often caused by polymicrobial infections, but sometimes, like some 0:28:59.600 --> 0:29:02.400 of them, bacteria that are associated with it are things 0:29:02.440 --> 0:29:07.080 like staff aureus e coli. One of the big problems 0:29:07.160 --> 0:29:11.000 with a Fournier's ganggreen is because if it extends to 0:29:11.360 --> 0:29:14.960 involve like near the anal sphincter or the perineum down 0:29:15.000 --> 0:29:17.880 towards the anal sphincter, then you have a really high risk, 0:29:18.000 --> 0:29:21.800 especially after surgery, of fecal contamination of the wound. So 0:29:21.840 --> 0:29:25.840 it's really hard to keep these wounds from getting like reinfected. 0:29:27.040 --> 0:29:29.400 Sometimes it has to go so far, like the surgical 0:29:29.400 --> 0:29:31.080 correction has to go so far as to do like 0:29:31.120 --> 0:29:35.040 a diverting colostomy just so that those tissues can actually heal. 0:29:35.120 --> 0:29:39.000 So this is a major major problem. And then there's 0:29:39.040 --> 0:29:42.640 also other areas of your body, like deep space fascia 0:29:42.680 --> 0:29:45.600 that you can get infections in. There's one called ludwings angina, 0:29:45.800 --> 0:29:47.600 which is an infection of the fascia of like the 0:29:47.600 --> 0:29:50.400 submandibular space, and there's a few other like deep neck 0:29:50.480 --> 0:29:53.160 space infections that you can get that are a necrotizing 0:29:53.200 --> 0:29:53.840 fasci idis. 0:29:54.360 --> 0:29:56.120 Those are very dangerous because they could. 0:29:55.960 --> 0:29:59.240 Potentially involve your airway, so that usually needs emergent surgery 0:29:59.280 --> 0:30:01.840 to like decompro us your airway and things like that. 0:30:03.080 --> 0:30:06.320 And then of course we talked about vibrio neckfash, which 0:30:06.360 --> 0:30:10.000 is a little different than our classic streptococcal neckfash. There's 0:30:10.040 --> 0:30:12.920 actually a they classify it into, like type one is 0:30:12.920 --> 0:30:17.680 the polymicrobial infections. Type two is Streptococcus or staff oureus. 0:30:18.160 --> 0:30:19.760 And there's some people that are like, we should have 0:30:19.760 --> 0:30:23.000 a type three for Vibrio plus or minus Clustridium. I 0:30:23.000 --> 0:30:25.200 don't know if that's like official yet. 0:30:24.960 --> 0:30:25.120 But. 0:30:26.560 --> 0:30:29.440 And that is what we see in association with marine 0:30:29.480 --> 0:30:32.680 life or like marine coastal waters, that kind of a thing. 0:30:33.240 --> 0:30:37.080 Like so subtropical tropical coastal waters. 0:30:37.040 --> 0:30:40.680 Not anymore because of climate change, right, talk more about that. 0:30:40.760 --> 0:30:44.000 I mean the water is warming, yes, yeah, exactly, yes. 0:30:43.880 --> 0:30:45.120 Yes, it likes warm water. 0:30:47.920 --> 0:30:50.040 But yeah, I mean, I don't know aeron if you 0:30:50.120 --> 0:30:52.280 have more questions, that's like the main thing that I have. 0:30:52.320 --> 0:30:54.200 I have more on like how we diagnose. 0:30:53.800 --> 0:30:55.880 It in that, but it's probably a little bit boring, 0:30:55.920 --> 0:30:59.120 and so tell me if you have more questions. Otherwise, 0:30:59.200 --> 0:31:01.040 I want to know what you know about how we 0:31:01.080 --> 0:31:01.600 got here. 0:31:02.280 --> 0:31:04.440 I mean, I guess most of my questions now are 0:31:04.480 --> 0:31:10.200 probably more epidemiological, like have we gotten better, Where is 0:31:10.240 --> 0:31:15.960 this happening? What you know, what advancements are there, potential advancements. 0:31:16.040 --> 0:31:18.600 Will AI help us diagnose? 0:31:19.160 --> 0:31:21.480 That's a fun question. Yes, I don't have an answer 0:31:21.480 --> 0:31:23.720 to that, but that's a fun question. 0:31:23.840 --> 0:31:25.360 Not that AI is the end all be all, but 0:31:25.720 --> 0:31:28.960 I feel like for diagnostic stuff, it is an interesting it. 0:31:28.920 --> 0:31:33.480 Is, especially especially for radiology diagnostics, and that is a 0:31:33.520 --> 0:31:36.320 big really like a lot of what research needs to 0:31:36.320 --> 0:31:40.960 be done is on how to better diagnose this quickness 0:31:41.040 --> 0:31:43.200 right and in the early stages of infection. 0:31:44.040 --> 0:31:46.320 Okay, so maybe that's a question how low can we 0:31:46.360 --> 0:31:48.840 get mortality down if you catch it early enough? And 0:31:48.880 --> 0:31:50.040 what is that early enough? 0:31:50.440 --> 0:31:53.080 We can get it down at least in the studies 0:31:53.120 --> 0:31:54.600 where they have looked at this, which have their own 0:31:54.640 --> 0:31:57.280 sets of biases, because they're like, you know, only looking 0:31:57.320 --> 0:31:59.080 at the things that they have diagnosed, and you know, 0:31:59.080 --> 0:32:01.680 so it's there's nuance there. But at least in the 0:32:01.720 --> 0:32:05.040 studies that have looked at this, average mortality is like 0:32:05.040 --> 0:32:07.719 twenty five to thirty five percent. And in the studies 0:32:07.760 --> 0:32:11.280 that have tried to compare early versus delayed debreedment, early 0:32:11.360 --> 0:32:13.480 debreedment can get it down to as low as close 0:32:13.520 --> 0:32:18.400 to ten percent. The biggest problem is those are all 0:32:18.440 --> 0:32:21.200 in studies where that has been identified, right, And so 0:32:21.640 --> 0:32:23.400 the question is like, how do we get better at 0:32:23.440 --> 0:32:25.680 identifying those ones that we missed who we sent home 0:32:25.680 --> 0:32:27.920 with antibiotics and then they came back and now they 0:32:27.920 --> 0:32:31.120 have an acritizing infection. So that's the tricky part, and 0:32:31.160 --> 0:32:38.440 we don't have great answers for that necessarily. Right erin, Erin, 0:32:38.960 --> 0:32:44.040 I know these bacteria have always been here. Sure, tell 0:32:44.080 --> 0:32:46.080 me about the necrotizing infections. 0:32:46.320 --> 0:32:48.080 Oh, do I want to know? I do? 0:32:48.920 --> 0:32:49.640 I think you do? 0:32:49.920 --> 0:32:51.120 I definitely do, I think you do. 0:32:51.360 --> 0:33:12.000 Okay, antibiotic resistant bugs aside, which I know is like 0:33:12.160 --> 0:33:17.240 a big thing to put aside. Yeah, there are relatively few, 0:33:17.480 --> 0:33:20.920 I would say, bacterial infections that have the power to 0:33:21.120 --> 0:33:24.120 transport us back to an era before we had any 0:33:24.160 --> 0:33:25.600 tools to fight these germs. 0:33:26.080 --> 0:33:30.120 Right, No, it's I mean necrotizing infections are terrifying, terrifying. 0:33:30.600 --> 0:33:32.800 And what I mean is that even in the most 0:33:32.840 --> 0:33:39.280 well equipped hospital, with the most skilled specialized infectious disease docs, surgeons, whatever, 0:33:39.760 --> 0:33:43.720 modern medicine is sometimes powerless to stop the ravages of 0:33:43.760 --> 0:33:48.760 necrotizing fasciitis. Regardless of the bacterium that's causing it. It 0:33:48.920 --> 0:33:53.640 is destructive, it's deadly, it's humbling in the way that 0:33:53.720 --> 0:33:57.000 it rejects the hundreds of years of scientific advancements that 0:33:57.040 --> 0:33:59.760 we've made in so many areas of medicine. 0:34:00.160 --> 0:34:00.360 YEP. 0:34:01.000 --> 0:34:05.960 I understand why nicknames like quote unquote, galloping gang green 0:34:06.400 --> 0:34:09.320 or flesh eating bacteria. I understand why those are frowned 0:34:09.360 --> 0:34:14.759 on by the medical community. They're sensationalist, they're stigmatizing, their imprecise, 0:34:15.360 --> 0:34:19.000 and they can incite undo fear and panic that this 0:34:19.239 --> 0:34:22.280 new deadly disease, like something out of a horror novel, 0:34:22.440 --> 0:34:25.520 is about to strike you down and everyone else in 0:34:25.560 --> 0:34:28.600 your family or community, because that's not the way that 0:34:28.600 --> 0:34:33.800 necrotizing fasciatis works. But I think that those names sensationalists, 0:34:33.880 --> 0:34:38.560 though they may be, also convey the genuine fear that 0:34:38.719 --> 0:34:42.239 comes with being largely powerless in the face of this 0:34:42.360 --> 0:34:46.440 deadly disease. And I think it could also be argued 0:34:46.520 --> 0:34:49.200 that they have helped raise awareness of the disease, and 0:34:49.280 --> 0:34:52.400 since time is certainly of the essence, that could maybe 0:34:52.440 --> 0:34:56.320 have saved lives in the past. But still we're sticking 0:34:56.320 --> 0:34:59.640 with necrotizing fasciatis for this episode or soft what is it? 0:34:59.719 --> 0:35:00.440 Soft tissue? 0:35:00.600 --> 0:35:03.000 Necrosisizing, negritizing infections. 0:35:03.880 --> 0:35:08.719 Okay, the words are all a jumble. Yes, So I've 0:35:08.719 --> 0:35:10.320 got a quote for you, and strap in because this 0:35:10.440 --> 0:35:12.360 is the first of many many quotes. 0:35:12.560 --> 0:35:13.279 Okay, can't wait. 0:35:13.360 --> 0:35:13.640 Quote. 0:35:14.280 --> 0:35:18.640 Few entities challenged the surgeon's clinical and operative skills as 0:35:18.760 --> 0:35:24.799 intensely as devastating necrotizing soft tissue infections. End quote. Yep, 0:35:25.760 --> 0:35:29.560 that statement. Although it was written in an article from 0:35:29.719 --> 0:35:33.880 nineteen ninety one Necrotizing Lesions of Soft Tissues or Review 0:35:33.920 --> 0:35:37.920 by Patino and Castro, that quote is still as relevant 0:35:37.960 --> 0:35:41.680 today as it was thirty four years ago, and in fact, 0:35:41.800 --> 0:35:45.080 a paper written eighteen years later in two thousand and 0:35:45.280 --> 0:35:49.960 nine reported that over the previous three decades, so from 0:35:51.080 --> 0:35:54.359 nineteen seventy nine to two thousand and nine, mortality from 0:35:54.480 --> 0:35:59.680 necrotizing fasciitis had not budged, despite better tools and more 0:35:59.719 --> 0:36:00.880 knowledge about the condition. 0:36:01.640 --> 0:36:02.960 Yeah, I'm surprised by that. 0:36:03.120 --> 0:36:07.160 Unfortunately, I know I'm not saying this to like terrify 0:36:07.400 --> 0:36:11.080 everyone and say let's jump on the catastrophizing train, just 0:36:11.160 --> 0:36:13.960 that we're still figuring it out. Modern medicine is still 0:36:14.040 --> 0:36:17.640 figuring it out, and we have been working on it 0:36:17.760 --> 0:36:18.440 for centuries. 0:36:18.880 --> 0:36:21.000 Yeah, we'll get to later. How rare these are. 0:36:21.160 --> 0:36:22.719 They're quite rare. 0:36:22.760 --> 0:36:23.440 They're quite rare. 0:36:23.600 --> 0:36:31.000 Yes, yep, not historically in certain situations. Yeah. So, when 0:36:31.200 --> 0:36:35.080 cases of an unusually virulent strain of group A strap 0:36:35.160 --> 0:36:37.600 began popping up in the mid to late eighties, the 0:36:37.760 --> 0:36:42.000 question was raised, is this something new? And I don't 0:36:42.040 --> 0:36:45.360 know how sincere of a question that was, although I 0:36:45.400 --> 0:36:48.360 did read one article that was titled flesh eating bacteria 0:36:48.400 --> 0:36:52.120 a new disease or old story? Because a quick review 0:36:52.160 --> 0:36:54.160 of the literature shows that the answer is that this 0:36:54.320 --> 0:36:58.640 is a very old story. Let's bring out some Hippocrates, right, Yes, 0:36:59.040 --> 0:37:04.319 fifth century DCEE, Volume one of Epidemics. Quote. Many were 0:37:04.360 --> 0:37:07.520 attacked by the aricipolus all over the body. When the 0:37:07.640 --> 0:37:10.720 exciting cause was a trivial accident or a very small wound, 0:37:11.120 --> 0:37:16.600 the ariciplus would quickly spread widely in all directions. Flesh, sinews, 0:37:16.680 --> 0:37:20.640 and bones fell away in large quantities. The flux which 0:37:20.719 --> 0:37:24.200 formed was not like puss, but a different sort of putrefaction, 0:37:24.520 --> 0:37:28.520 with a copious and varied flux. Fever was sometimes present 0:37:28.640 --> 0:37:32.480 and sometimes absent. There were many deaths. The course of 0:37:32.520 --> 0:37:34.840 the disease was the same to whatever part of the 0:37:34.880 --> 0:37:38.719 body it spread. Many lost the arm and the entire forearm. 0:37:39.200 --> 0:37:41.800 If the malady settled in the sides, there was rotting 0:37:41.960 --> 0:37:45.719 either before or behind. In some cases the entire thigh 0:37:45.960 --> 0:37:48.719 was bared, or the shin and the entire foot. But 0:37:48.840 --> 0:37:52.080 the most dangerous cases of all such cases were when 0:37:52.160 --> 0:37:55.680 the pubis and genital organs were attacked. End quote. 0:37:57.480 --> 0:38:00.680 The way that that fluid is described to is called 0:38:00.920 --> 0:38:04.600 dishwater fluid because it is like, it's not a pus, 0:38:04.960 --> 0:38:09.120 it's not a purulent infection. It's like a very liquity 0:38:09.200 --> 0:38:11.000 fluid that's kind of foamy and looks. 0:38:10.840 --> 0:38:14.400 Like that grayish after you've washed dishes. 0:38:14.800 --> 0:38:15.000 Yeah. 0:38:17.320 --> 0:38:18.800 Uh, it's horrific. 0:38:19.160 --> 0:38:19.760 It's horrific. 0:38:19.880 --> 0:38:20.120 Yeah. 0:38:21.400 --> 0:38:25.880 Yeah. And that quote though, like, did that sound to 0:38:26.000 --> 0:38:29.279 you like necrotizing fasci idis? I mean absolutely right, Like 0:38:29.440 --> 0:38:33.560 definitely yeah. And I think that this brings to light 0:38:33.760 --> 0:38:38.440 one of the unique or interesting facets of necrotizing fasci 0:38:38.520 --> 0:38:43.239 itis is that finding historical traces of necrotizing fasci idis 0:38:43.280 --> 0:38:47.640 in like medical texts requires much less guesswork because its 0:38:47.719 --> 0:38:51.600 symptoms and clinical course are so distinctive. It's not like 0:38:52.360 --> 0:38:55.440 there's a fever and maybe a rash and some malaise 0:38:55.640 --> 0:38:58.520 and maybe a sore throat and like maybe your head hurts. 0:38:58.640 --> 0:39:02.280 You know, it's it's it's necrotizing fasciidis. Whether it goes 0:39:02.440 --> 0:39:07.040 by necrotizing fasciitis or malignant ulcer, or a gangrenous ulcer, 0:39:07.200 --> 0:39:14.800 putrid ulcer, fagiadina, phagidenic ulcer, fajidina gangrenosa, or hospital gangreene, 0:39:15.400 --> 0:39:17.560 all of the whether it's called any of those things, 0:39:17.800 --> 0:39:22.040 the description will pretty clearly point towards necrotizing fasciidis as 0:39:22.080 --> 0:39:25.840 the culprit. And so digging back through the medical literature, 0:39:26.080 --> 0:39:29.200 we can find traces of this condition dating back at 0:39:29.360 --> 0:39:33.040 least to the late eighteenth century in France, where a 0:39:33.120 --> 0:39:36.440 doctor out of hospital for the impoverished described it, and 0:39:36.719 --> 0:39:39.719 it was also mentioned in an eighteen oh four book 0:39:39.880 --> 0:39:43.520 on nautical medicine, where it was thought to be newly 0:39:43.680 --> 0:39:47.840 emergent in the British home seies, quote unquote, mostly appearing 0:39:47.880 --> 0:39:51.360 in those who had returned from long cruises in warm regions. 0:39:52.920 --> 0:39:55.000 I don't think it was new, but I think, like 0:39:55.120 --> 0:39:57.000 you said, it was rare, and so it was like 0:39:57.080 --> 0:39:58.239 how widely known was it? 0:39:58.680 --> 0:39:59.040 Anyway? 0:39:59.120 --> 0:40:03.000 So I've go got a quote for you from this 0:40:03.320 --> 0:40:07.080 this nautical medicine book quote. In the summer of seventeen 0:40:07.160 --> 0:40:10.640 ninety nine, the malignant ulcer made its appearance on board 0:40:10.680 --> 0:40:14.560 the Temaare with all the characteristic symptoms in virulence which 0:40:14.680 --> 0:40:18.520 marked it in other ships. Every wound, abrasion of the cuticle, 0:40:18.840 --> 0:40:23.160 blistered part, scald or burn passed rapidly through the various 0:40:23.160 --> 0:40:27.640 stages of inflammation, gangreen and spaceless in a few days, 0:40:27.840 --> 0:40:31.320 leaving the bones almost bare from the separation of immense 0:40:31.360 --> 0:40:40.480 slufs en oohlarin yep. The ship the Saturn seemed especially 0:40:40.600 --> 0:40:43.800 unlucky when it came to this disease. And there was 0:40:43.880 --> 0:40:48.320 one case in particular that is truly horrific, like historically horrific. 0:40:48.840 --> 0:40:53.680 So while in port, this sailor had contracted gonorrhea, and 0:40:53.840 --> 0:40:57.000 it just kept getting worse, like the inflammation kept getting worse, 0:40:57.160 --> 0:41:00.439 the everything kept get worse. 0:41:00.719 --> 0:41:01.040 Quote. 0:41:03.160 --> 0:41:05.640 If you're squeamish, you may want to pause here or 0:41:05.760 --> 0:41:09.839 skip ahead. Yeah, thirty seconds feet I mean you've tuned 0:41:09.880 --> 0:41:12.359 into an episode on acrotizing fasci itis. So like you've 0:41:12.400 --> 0:41:14.759 made it this it's a little bit of a yeah, yeah, 0:41:14.840 --> 0:41:19.840 here we go. Quote. The symptoms advanced by two hasty 0:41:19.920 --> 0:41:23.160 strides to be arrested by any resources of medical skill. 0:41:23.760 --> 0:41:26.600 The gland of the penis soon dropped off, but the 0:41:26.680 --> 0:41:29.719 misery of the patient did not stop there. The whole 0:41:29.800 --> 0:41:32.759 body of the penis passed quickly through the stages of 0:41:32.880 --> 0:41:38.160 excessive excitement and inflammation to complete gangreen and mortification and 0:41:38.280 --> 0:41:41.800 separate it at its very kura. The whole length of 0:41:41.880 --> 0:41:45.800 the urethra to the bulb sloughed away, and also the scrotum, 0:41:46.080 --> 0:41:50.239 leaving the testes and spermatic vessels barely covered with cellular substance. 0:41:51.120 --> 0:41:56.160 He died end quote. Of course, of course he died. 0:41:56.320 --> 0:41:57.040 Of course he died. 0:41:58.280 --> 0:42:00.640 How to have to live through all of that? 0:42:01.239 --> 0:42:01.480 I know? 0:42:01.680 --> 0:42:03.280 And then oh my gosh. 0:42:05.160 --> 0:42:09.720 And then literally like the next sentence, the author says, 0:42:10.280 --> 0:42:12.960 cases like these have been frequent on board these ships. 0:42:14.000 --> 0:42:17.319 And I don't know what these means. Does it mean 0:42:17.480 --> 0:42:19.640 like penis is falling off or does it mean like 0:42:20.320 --> 0:42:27.879 necrotizing inclignant ulser? Yeah? Right, yeah, okay, there's more. I yeah, 0:42:29.320 --> 0:42:32.400 so there's another book published in eighteen eighteen on the 0:42:32.480 --> 0:42:38.560 subject called Observations on Phagiadina Gangrenosa by HH Blackadder that 0:42:38.680 --> 0:42:41.160 discusses the condition as though it was well known, at 0:42:41.239 --> 0:42:43.880 least to military surgeons. So there's a passage from that 0:42:43.960 --> 0:42:47.120 book that is basically an echo of the quote that 0:42:47.160 --> 0:42:52.000 I read earlier. Quote gangrenous fagidina is one of those 0:42:52.200 --> 0:42:57.400 diseases which happily seldom falls under the observation of civil practitioners. 0:42:58.000 --> 0:42:59.880 But on the other hand, it is one of the 0:43:00.000 --> 0:43:02.759 those which army and navy surgeons, during a time of 0:43:02.840 --> 0:43:06.480 active hostilities, are frequently called upon to resist with all 0:43:06.600 --> 0:43:11.520 the resources of their art. No disease requires more circumspection 0:43:11.840 --> 0:43:14.920 and personal attention on the part of the surgeon, and 0:43:15.320 --> 0:43:18.840 when the circumstances in which it occurs, the occasional rapidity 0:43:18.920 --> 0:43:22.600 of its progress, the extent of its ravages, and fatal 0:43:22.719 --> 0:43:26.640 tendency are considered, it may justly be esteemed one of 0:43:26.719 --> 0:43:31.960 the most dreadful diseases to which mankind are subject end quote. 0:43:32.960 --> 0:43:36.560 So it's like this, this is the worst, Yeah, this 0:43:36.760 --> 0:43:40.640 is it. He also talks about how important it is 0:43:40.760 --> 0:43:44.279 to recognize this disease quickly. Quote where there is any 0:43:44.400 --> 0:43:47.320 even the smallest reason to dread the occurrence of this 0:43:47.480 --> 0:43:51.320 disease too early or too many precautions cannot be taken 0:43:51.719 --> 0:43:54.120 with the view of securing its speedy detection. 0:43:54.560 --> 0:43:55.000 End quote. 0:43:57.239 --> 0:43:59.919 I think it's like it's that was from eighteen eighteen, 0:44:00.400 --> 0:44:04.040 and so yeah, it's just. 0:44:05.520 --> 0:44:07.960 They knew all the way back then how important it 0:44:08.160 --> 0:44:09.680 was to be quick about it. Yeah. 0:44:09.960 --> 0:44:11.960 Yeah, we're still having trouble with that. 0:44:12.440 --> 0:44:14.799 We are, we are, And I mean it's hard, it's hard. 0:44:15.120 --> 0:44:18.200 It's hard. I'm also like, this person's not like prophetic 0:44:18.280 --> 0:44:21.560 by any means, right, Like I'm cherry picking these quotes. 0:44:21.600 --> 0:44:23.680 He also used arsenic to treat it, and he blamed 0:44:23.719 --> 0:44:26.480 the weather for when it showed up. 0:44:27.000 --> 0:44:30.160 Yeah, maybe they were all vibryo maybe yeah. 0:44:30.320 --> 0:44:34.120 I mean, but I think the thing that I appreciated 0:44:34.160 --> 0:44:36.719 the most about that entire Like I didn't read the 0:44:36.760 --> 0:44:40.279 whole book, but in the introduction he one of the 0:44:40.360 --> 0:44:43.759 things he says is the author is fully aware of 0:44:43.880 --> 0:44:47.320 his defects to kind of like head off anti criticism. 0:44:47.400 --> 0:44:49.879 He's like, I'm yeah, I know. I was like, We're 0:44:49.920 --> 0:44:52.200 going to start every single episode like that from now on. 0:44:52.880 --> 0:44:53.520 Yep, yep. 0:44:54.680 --> 0:44:57.319 But so throughout the rest of the eighteen hundreds. More 0:44:57.440 --> 0:45:01.239 case descriptions followed, often though not always, associated with some 0:45:01.400 --> 0:45:05.800 sort of military or nautical endeavor, in which cases it 0:45:05.960 --> 0:45:09.640 may have been more contagious rather than the sporadic cases 0:45:09.680 --> 0:45:13.440 that are seen in the general public. And once you 0:45:13.600 --> 0:45:18.680 saw it, you never forgot it, a surgeon named John 0:45:18.800 --> 0:45:22.360 Hennan said in eighteen twenty quote, to those who have 0:45:22.480 --> 0:45:25.080 seen it, once a glance at the sore or even 0:45:25.200 --> 0:45:28.600 the smell of the ward will immediately discover it. It 0:45:28.680 --> 0:45:32.000 can scarcely be confounded with any other disease or any 0:45:32.160 --> 0:45:33.680 other species of ulcers. 0:45:34.000 --> 0:45:34.520 End quote. 0:45:37.760 --> 0:45:43.000 Yeah, distinctive. Yeah. Most scholars put the next big event 0:45:43.080 --> 0:45:46.200 in the history of necrotizing fasciitis in the aftermath of 0:45:46.239 --> 0:45:50.960 the American Civil War, when medical officers such as Joseph Jones, 0:45:51.000 --> 0:45:53.520 who was in the Confederate Army, described some of the 0:45:53.600 --> 0:45:58.200 horrors that they witnessed. Jones is often credited with providing 0:45:58.280 --> 0:46:02.560 the first modern description of necrotizing fasciitis, which he referred 0:46:02.600 --> 0:46:07.560 to as hospital gangreen quote. In some cases, the progress 0:46:07.600 --> 0:46:10.920 of the disease is rapid and terrible. The edges of 0:46:10.960 --> 0:46:14.120 the wound become hardened and inverted. The surface of the 0:46:14.200 --> 0:46:18.720 wound rises up into a pulpy, ragged, gray and greenish mass. 0:46:19.440 --> 0:46:22.840 When the sloughs are detached, the disease attacks other adjacent 0:46:22.880 --> 0:46:26.640 structures from day to day, extending its ravages both in 0:46:26.840 --> 0:46:31.040 length and breadth. Most commonly, after the muscles have been exposed, 0:46:31.200 --> 0:46:35.120 they continue to be gradually dissected. Their connecting membrane is 0:46:35.239 --> 0:46:39.680 completely destroyed, and they are left covered with an offensive, 0:46:39.960 --> 0:46:44.399 greasy looking matter. As the disease advances, hemorrhage from small 0:46:44.520 --> 0:46:47.719 vessels is a common occurrence, and in the more advanced stages, 0:46:47.960 --> 0:46:50.880 some of the large vessels give way and the patient 0:46:51.000 --> 0:46:54.520 is frequently destroyed by the consequent hemorrhage. End quote. 0:47:00.080 --> 0:47:06.439 Yeah, yeah, it's a truly I mean, I flesh eating 0:47:06.520 --> 0:47:12.440 bacteria is not a term that is like nice to hear, 0:47:12.560 --> 0:47:15.080 but it is. I understand how it got that nickname. 0:47:15.239 --> 0:47:18.360 Like it is what it feels like, what it looks like, 0:47:18.719 --> 0:47:19.719 you know, I. 0:47:19.760 --> 0:47:23.480 Mean that's what it was like Fajadina was eating away 0:47:23.719 --> 0:47:27.239 like that. It is a describes what happens. I think 0:47:27.280 --> 0:47:30.840 it's also like when it was happening in military hospitals 0:47:30.920 --> 0:47:33.440 it's possible that there were like outbreaks where it was 0:47:33.560 --> 0:47:36.280 contagious because you had a bunch of Group A strap 0:47:36.400 --> 0:47:40.600 in that hospital and horrible sanitize, you know, sanitary conditions, 0:47:41.040 --> 0:47:44.400 and so it spread. But like that, I think that 0:47:44.640 --> 0:47:47.920 is sort of the what conjures today, that idea of 0:47:48.080 --> 0:47:50.799 like flesh eating bacteria is gonna it's gonna spread, it's 0:47:50.840 --> 0:47:51.080 going to. 0:47:51.040 --> 0:47:52.360 Be coming for you, and it's not. 0:47:52.600 --> 0:47:54.200 That's not the way that it works. 0:47:54.280 --> 0:47:54.799 Yeah. Yeah. 0:47:54.840 --> 0:47:58.440 Hospital gangreen is also quite a misnomer for today's infections. 0:47:58.480 --> 0:48:01.000 It's usually not at all hospit it required. 0:48:01.080 --> 0:48:04.520 Right, definitely, that was like it probably should have been 0:48:04.680 --> 0:48:09.680 military hospital gangren. Yeah, and Joseph Jones, this guy, he 0:48:09.840 --> 0:48:14.080 was more than qualified to describe this disease. Over twenty 0:48:14.200 --> 0:48:17.600 six hundred cases of hospital gangrene had been diagnosed in 0:48:17.680 --> 0:48:22.719 soldiers during the American Civil War. Nearly half of them died. 0:48:22.920 --> 0:48:25.480 That's a lot, holy guacamole. 0:48:26.000 --> 0:48:29.800 Yeah, yeah, and those who lived, like the around the 0:48:29.920 --> 0:48:33.560 half of those who lived, they recovered, but they did 0:48:33.640 --> 0:48:36.480 so at the cost of limbs or multiple limbs, which 0:48:36.600 --> 0:48:41.120 had to be amputated. And in a different book, Jones 0:48:41.280 --> 0:48:44.440 recalls the first case of hospital gangrene that he observed, 0:48:45.360 --> 0:48:48.400 which was in a young man, a volunteer from Florida 0:48:48.520 --> 0:48:51.560 who was stabbed in the scrotum, not during battle, but 0:48:51.680 --> 0:48:55.520 during a fight at the drinking saloon. No, yeah, I know. 0:48:55.760 --> 0:48:58.399 So he was brought to the hospital eight hours after 0:48:58.520 --> 0:49:01.120 being stabbed, and he died less than a week later. 0:49:01.880 --> 0:49:05.719 I decided to after reading through the full description, I 0:49:05.880 --> 0:49:08.320 was like, I'm actually not going to quote all of this. 0:49:08.480 --> 0:49:12.239 I'm sparing you the full description and also involves it 0:49:12.480 --> 0:49:16.040 another penis sloughing off. But there's a part that really 0:49:16.360 --> 0:49:19.960 stuck out to me at the end quote, the patient 0:49:20.080 --> 0:49:22.919 retained his senses to within a few moments of death 0:49:23.239 --> 0:49:27.000 and was at no point restless, No active pain was suffered, 0:49:27.200 --> 0:49:30.640 and the patient appeared to be insensible to his distressing condition. 0:49:31.520 --> 0:49:34.440 He expressed no fears of death, did not complain of 0:49:34.560 --> 0:49:38.040 the horrid stench, and although fully warned of his true 0:49:38.080 --> 0:49:42.200 situation and informed that every hope of life had vanished, 0:49:42.760 --> 0:49:45.400 he actually traded for a watch two or three hours 0:49:45.480 --> 0:49:46.200 before his death. 0:49:46.840 --> 0:49:47.360 End quote. 0:49:48.040 --> 0:49:50.000 Isn't that heartbreaking? 0:49:50.160 --> 0:49:52.360 Breaking? Absolutely heartbreaking? 0:49:53.520 --> 0:49:53.560 Ugh? 0:49:55.840 --> 0:49:56.040 Yeah. 0:49:57.239 --> 0:50:00.880 And so to round out this discussion of historic and 0:50:00.960 --> 0:50:04.480 negritizing fasciatis, and especially as it applies to the genitals. 0:50:04.520 --> 0:50:07.440 I have to mention Fournier and the gangreen that bears 0:50:07.480 --> 0:50:10.799 his name. So in his work he was a quote 0:50:10.880 --> 0:50:15.279 unquote venereologist, so he studied sexually transmitted infections, and in 0:50:15.360 --> 0:50:19.560 eighteen eighty three he described five patients with necrotizing fasciitis 0:50:19.640 --> 0:50:23.839 in their genitals and paraneal region. I wasn't sure why 0:50:24.120 --> 0:50:27.840 this got a separate name, like why is this But 0:50:28.040 --> 0:50:32.200 unless it's just that's where it happens more frequently, Like why, Yes, that's. 0:50:32.040 --> 0:50:33.160 What we call it when it's there. 0:50:33.520 --> 0:50:35.120 Okay, So it's just sort of like almost like a 0:50:35.280 --> 0:50:37.080 historical relic in that way. 0:50:37.160 --> 0:50:38.360 Yeah, as far as I know. 0:50:38.560 --> 0:50:41.040 I mean the same thing with like Ludwing's angina is 0:50:41.200 --> 0:50:43.920 in a specific location, so it's like to describe the 0:50:44.239 --> 0:50:46.520 location of where of where it is, but it is 0:50:46.560 --> 0:50:49.080 an ecritizing fasci idis of the fashion of that area. 0:50:49.440 --> 0:50:54.680 Right, So, until germ theory was fully established, people really 0:50:54.920 --> 0:50:58.480 did not know where hospital gangreen came from or how 0:50:58.520 --> 0:51:01.200 to treat it. Like Jones thought it was the crowded 0:51:01.320 --> 0:51:06.120 conditions and poor ventilation in the hospitals. Another surgeon pinned 0:51:06.160 --> 0:51:10.640 it on scurvy and nutritional status. There's the guy who 0:51:10.680 --> 0:51:13.640 thought it was about weather, Thomas Trotter, who was the 0:51:13.680 --> 0:51:16.080 author of the eighteen oh four book on Nautical Medicine. 0:51:16.120 --> 0:51:18.520 He pointed out over and over again to alcohol, Like 0:51:18.680 --> 0:51:21.000 every case that he described, he was like, and this 0:51:21.200 --> 0:51:24.279 person drank this cheap alcohol, and this person drank this 0:51:24.400 --> 0:51:29.080 cheap alcohol. Once people were able to identify the causative 0:51:29.080 --> 0:51:32.640 bacteria in the wounds, that didn't necessarily clear things up right, Like, 0:51:32.719 --> 0:51:38.680 we're still at a disadvantage because it was also turning 0:51:38.719 --> 0:51:41.480 out to be multiple different microbes just a mix of 0:51:41.560 --> 0:51:46.799 them sometimes. And interest in the condition, though I found 0:51:46.840 --> 0:51:50.840 this fascinating, seemed to fall in the late eighteen hundreds 0:51:50.840 --> 0:51:53.000 early nineteen hundreds. It was like kind of like this 0:51:53.200 --> 0:51:56.239 was a big deal, Rear treatises about it, and then 0:51:56.280 --> 0:51:58.200 it was kind of like eh. And there was a 0:51:58.239 --> 0:52:01.800 physician who wrote in nineteen oh eight that quote hospital 0:52:01.840 --> 0:52:05.400 gangreen so called has been in years past the terror 0:52:05.520 --> 0:52:09.920 of military surgeons and camp hospitals. It has almost completely 0:52:10.040 --> 0:52:15.200 disappeared from observation and is now practically never seen end quote. 0:52:15.960 --> 0:52:16.760 Isn't that interesting? 0:52:17.080 --> 0:52:17.279 Yeah? 0:52:17.280 --> 0:52:18.320 Why what changed? I? 0:52:18.360 --> 0:52:18.680 Don't know. 0:52:19.120 --> 0:52:22.759 So there is a thought. Do you remember when we 0:52:22.880 --> 0:52:26.880 talked about Strap last and we talked about this sudden 0:52:27.040 --> 0:52:32.280 decrease in and I'm wondering whether it's in scarlet pathogen shift. 0:52:32.480 --> 0:52:34.680 Yeah, so all of a sudden, we have ones that whatever, 0:52:34.960 --> 0:52:37.120 whatever toxins they're making, are not the ones that are 0:52:37.160 --> 0:52:40.560 more likely to cause an acritizing infection. Maybe that's super interesting. 0:52:40.880 --> 0:52:42.160 Yeah, So it could be that. 0:52:42.320 --> 0:52:44.480 I don't I should have looked specifically at that, but 0:52:44.640 --> 0:52:45.120 I didn't. 0:52:45.960 --> 0:52:48.480 There was a paper that mentioned a little bit of that, 0:52:48.600 --> 0:52:51.239 and there was also another paper that looked at genomes 0:52:51.400 --> 0:52:54.839 of the group a Strap today and sort of any 0:52:54.880 --> 0:52:57.160 sort of shifts in that as well. And I didn't 0:52:57.200 --> 0:52:59.440 get into the nitty gritty of it, but like, it 0:52:59.560 --> 0:53:03.600 does seem like there could be, like the biology is 0:53:03.640 --> 0:53:05.800 there for these types of shifts. 0:53:05.880 --> 0:53:07.719 It's a plausible explanation, it is. 0:53:07.920 --> 0:53:12.480 Yeah, yeah, yeah, but yeah, that whole Oh it's never 0:53:13.080 --> 0:53:15.200 it's a disease of the past. I was a little 0:53:15.200 --> 0:53:18.919 bit of a premature celebration. The disease continued to pop 0:53:19.040 --> 0:53:21.719 up both in times of war, like in World War One, 0:53:22.000 --> 0:53:24.759 and in the general public just in other times like 0:53:24.960 --> 0:53:27.880 the outbreak that involved at least twenty cases in China, 0:53:28.000 --> 0:53:31.880 which was reported on by a physician named Frank Melanie 0:53:32.000 --> 0:53:35.240 in nineteen twenty four. And so this actually his description 0:53:35.360 --> 0:53:38.919 marks the first twentieth century description of the disease where 0:53:38.960 --> 0:53:42.480 he also linked it to particular organisms group. 0:53:42.280 --> 0:53:44.000 A strap, namely ok okay. 0:53:45.080 --> 0:53:49.440 And then in nineteen fifty one Hospital Ganggreen malignant ulcer 0:53:49.760 --> 0:53:53.279 phaegiadina gangrenosa, whatever else it was called, it was rebranded 0:53:53.480 --> 0:53:58.000 as necrotizing fasciitis. And this was a name chosen by 0:53:58.280 --> 0:54:03.720 physician Ben Wilson because fascial necrosis is the most consistent 0:54:03.840 --> 0:54:08.080 manifestation of the disease end quote. And in this landmark 0:54:08.160 --> 0:54:10.560 paper he went through what was known about the course 0:54:10.600 --> 0:54:14.760 of disease, causes, treatment outcomes in epidemiology, you know, essentially 0:54:14.920 --> 0:54:17.960 boiling down to rare but not unheard of. Time is 0:54:18.000 --> 0:54:20.800 of the essence case fatality rate is lower than in 0:54:20.880 --> 0:54:25.680 past decades thanks to early recognition, surgery and antibiotics. Yeah, 0:54:27.040 --> 0:54:30.960 and so while the condition was known in medical circles 0:54:31.600 --> 0:54:34.359 rare though it was I think again as we talked 0:54:34.360 --> 0:54:38.640 about memorable, rare but memorable. It was known from at 0:54:38.760 --> 0:54:42.439 least the mid twentieth century. It escaped public attention until 0:54:42.520 --> 0:54:46.120 around the nineteen nineties. And this is I would say 0:54:46.200 --> 0:54:49.880 largely that's a generalization, but that's around the nineties is 0:54:49.880 --> 0:54:53.840 when a series of cases received a ton of media attention. 0:54:54.640 --> 0:54:58.759 There was one outbreak, in particular in a place I'm 0:54:58.880 --> 0:55:04.040 going to say this wrong, Gloucestershire, involving at least seven individuals, 0:55:04.280 --> 0:55:07.759 and it led to headlines that were like, hospitals get 0:55:07.920 --> 0:55:12.200 warning on killer bug, mystery bug kills, three more flesh 0:55:12.239 --> 0:55:15.680 eating bug kills, young mother, I watched killer bug eat 0:55:15.719 --> 0:55:19.840 my body, you know, things like super sensationalist headlines, right, 0:55:19.920 --> 0:55:20.160 and so. 0:55:20.320 --> 0:55:21.960 The monsters inside me kind of thing. 0:55:22.360 --> 0:55:25.719 Yes, even though that is partially where I got the 0:55:25.800 --> 0:55:32.000 interest in parasitology. Yeah, but this also it seemed not 0:55:32.160 --> 0:55:34.560 like shared exposure but more like coincidence that these people 0:55:34.600 --> 0:55:39.480 were getting accortizing fasciitis. Interesting, but any factual reporting of 0:55:39.680 --> 0:55:42.839 that or exploration of that nuance it got drowned out 0:55:43.040 --> 0:55:46.160 by these sensationalists headlines and fear mongering. But like I 0:55:46.280 --> 0:55:48.640 pointed out at the top, there might have been the 0:55:48.719 --> 0:55:53.040 positive effect of improving recognition, you know, just like knowing 0:55:53.160 --> 0:55:56.800 what it is and that it exists right right, and 0:55:57.000 --> 0:56:02.080 sure enough. It was interesting to see that following this reporting, 0:56:02.640 --> 0:56:06.280 countries around the world began to also report, like release 0:56:06.360 --> 0:56:09.440 reports on necortizing fasci idis at higher rates than previously 0:56:09.600 --> 0:56:14.279 seen in cases often following like a surgical procedure. And 0:56:14.360 --> 0:56:17.680 so this might have helped people, whether in the community 0:56:17.800 --> 0:56:21.640 or physicians, recognize some early warning signs in themselves or 0:56:21.760 --> 0:56:25.239 their patients. But there's also a cost, of course, to 0:56:25.360 --> 0:56:28.440 this type of reporting. It contributes to the stigma that 0:56:28.760 --> 0:56:31.640 many people who were covering from necortizing fasci idis face. 0:56:32.200 --> 0:56:34.560 You know, the way that we talk about disease, even 0:56:34.880 --> 0:56:39.799 legitimately scary ones like necrotizing fasci idis. It really does matter. 0:56:40.160 --> 0:56:43.960 But yeah, that's all I have for the history of 0:56:44.760 --> 0:56:47.640 neck fash. So, Aaron, why don't you tell us what's 0:56:47.719 --> 0:56:49.720 happening with this condition today? 0:56:50.120 --> 0:56:50.480 All right? 0:56:50.840 --> 0:56:51.400 I'd love to. 0:57:24.440 --> 0:57:29.520 Today, thankfully. Necrotizing soft tissue infections, including neckritizing fascia idis, 0:57:30.000 --> 0:57:34.560 are relatively rare. However, we don't have great numbers on them. 0:57:36.000 --> 0:57:40.200 So group A strep infections like invasive group based strap infections, 0:57:40.200 --> 0:57:46.080 which includes necritizing fasci itis, but also includes other types 0:57:46.120 --> 0:57:49.320 of infections those are reportable in the US, so we 0:57:49.520 --> 0:57:52.000 know that their rate tends to be aboutzero point four 0:57:52.120 --> 0:57:56.600 per one hundred thousand in the US. But group A 0:57:56.720 --> 0:58:01.280 strap only accounts for a proportion of neckritizing fasciaitis or 0:58:01.360 --> 0:58:05.880 neckrotizing soft tissue infections more generally, and what proportion I 0:58:06.080 --> 0:58:09.600 don't know. I from what I can tell, the scientific 0:58:09.640 --> 0:58:12.400 community at large, the medical community doesn't necessarily have a 0:58:12.480 --> 0:58:15.640 great handle on that. What's very interesting is that I 0:58:15.720 --> 0:58:18.960 read one paper which I'll link to out of China 0:58:19.040 --> 0:58:21.480 that was quite recent that looked at in their hospital 0:58:21.520 --> 0:58:24.120 system just in one small part of China, and they 0:58:24.400 --> 0:58:28.480 had hardly any group base strip in that particular population. Huh, 0:58:28.720 --> 0:58:31.880 So I think it really varies location to location. Maybe 0:58:31.960 --> 0:58:35.040 it does vary based on, you know, what stereotypes are 0:58:35.320 --> 0:58:38.720 most prevalent, what toxins are being produced, et cetera. But 0:58:38.920 --> 0:58:41.960 across the board papers that tried to estimate the incidents 0:58:42.080 --> 0:58:45.520 of just necrotizing fasciitis, regardless of the type or the 0:58:46.080 --> 0:58:49.640 causative agent. In the US, it's estimated at like eight 0:58:49.720 --> 0:58:53.160 to ten cases per one hundred thousand individuals, and it 0:58:53.320 --> 0:58:56.800 really can vary geographically across the globe, from like less 0:58:56.840 --> 0:58:59.560 than one per one hundred thousand in some studies in 0:58:59.600 --> 0:59:03.480 some parts the world, to twenty cases or more per 0:59:03.600 --> 0:59:06.919 one hundred thousand people in other parts. I will say 0:59:07.320 --> 0:59:09.760 that if you dig deep in these papers, some of 0:59:09.800 --> 0:59:12.680 the studies that are reporting those higher end numbers are 0:59:12.800 --> 0:59:16.320 citing how many cases there are per hospital admission, not 0:59:16.960 --> 0:59:20.959 how many cases there are per general population mission. That's 0:59:21.040 --> 0:59:24.680 going to be quite inflated. But in any case, it 0:59:24.760 --> 0:59:29.000 can really range. What unfortunately doesn't have as huge of 0:59:29.040 --> 0:59:32.960 a range is the mortality rate, and that remains quite high. 0:59:34.560 --> 0:59:37.920 Some studies report a mortality rate as high as forty percent, 0:59:38.200 --> 0:59:40.800 and so in particular studies or in particular areas, the 0:59:40.840 --> 0:59:44.200 mortality rate can really be quite high. But on average globally, 0:59:44.320 --> 0:59:47.920 for the last like you mentioned, airing twenty plus something years, 0:59:48.720 --> 0:59:52.600 it really hasn't changed. The mortality rate on average is 0:59:52.720 --> 0:59:56.280 between twenty five and thirty or thirty five percent. It's 0:59:56.680 --> 0:59:59.640 only in the last couple of years that we've seen 0:59:59.680 --> 1:00:03.800 study more often reporting rates closer to twenty percent. So 1:00:03.880 --> 1:00:07.320 we're seeing maybe some suggestion of a bit of a drop. Okay, 1:00:08.240 --> 1:00:10.200 Like I mentioned some of the studies that are just 1:00:10.360 --> 1:00:14.040 looking at treatments, so they're looking at kind of a 1:00:14.160 --> 1:00:17.440 more well defined population. It's not these like larger retrospective 1:00:17.440 --> 1:00:19.960 studies and things like that. But some of these papers 1:00:20.080 --> 1:00:23.640 suggest that we could be reducing mortality rates to ten 1:00:23.760 --> 1:00:27.960 percent with correct identification and access to surgical management. 1:00:28.880 --> 1:00:32.400 But that is still really high. Like a ten percent. 1:00:32.200 --> 1:00:36.240 Mortality rate is terrifying, and that's the lowest that we've 1:00:36.280 --> 1:00:37.800 been able to get it in studies. 1:00:39.560 --> 1:00:43.600 Yikes, I know, and what is scary. 1:00:43.640 --> 1:00:46.360 And I don't want to necessarily be fear mongering about 1:00:46.400 --> 1:00:49.880 this because again, this is still quite a rare disease, 1:00:51.120 --> 1:00:56.400 but it does seem to be increasing in number. Yes, 1:00:58.800 --> 1:01:00.800 So according to analysis that was published I think in 1:01:00.840 --> 1:01:03.439 twenty twenty three from CDC data that went from two 1:01:03.480 --> 1:01:04.960 thousand and three to twenty twenty. 1:01:06.080 --> 1:01:09.880 Okay, there was an increase. Oh I saw this paper. 1:01:10.000 --> 1:01:13.320 Yeah, yeah, there was an increase of like one hundred 1:01:13.360 --> 1:01:19.520 and twenty percent of deaths associated with necrotizing soft tissue infections. 1:01:20.680 --> 1:01:23.080 Despite the fact that we are at least in theory, 1:01:23.160 --> 1:01:26.440 getting better at treatment right or at least not getting 1:01:26.480 --> 1:01:30.000 worse right, So deaths went from eight hundred and twenty 1:01:30.080 --> 1:01:32.640 four in two thousand and three to one thousand, eight 1:01:32.720 --> 1:01:34.600 hundred and forty two in twenty twenty. 1:01:35.280 --> 1:01:39.680 Is there any difference in like diagnostic or reporting or 1:01:39.720 --> 1:01:42.440 anything like that, or is that simply just the number 1:01:42.520 --> 1:01:43.080 of cases. 1:01:43.600 --> 1:01:44.880 It's a really good question. 1:01:45.120 --> 1:01:48.120 As far as I know, there's not any differences in 1:01:48.600 --> 1:01:50.680 you know, reporting or things like that, because there hasn't 1:01:50.720 --> 1:01:53.160 been a change in like what's required to report versus 1:01:53.200 --> 1:01:55.640 what's not. This is all just still like they've gathered 1:01:55.680 --> 1:01:58.160 this data after the fact. It's not necessarily like it's 1:01:58.240 --> 1:02:04.520 not as easily accessible. I would say we are, and 1:02:04.600 --> 1:02:07.480 I don't have necessarily data to back this up, but 1:02:07.720 --> 1:02:10.160 I would hope that we are getting better rather than 1:02:10.200 --> 1:02:12.880 worse at detecting it because of advances in things like 1:02:12.960 --> 1:02:16.439 CT technology. There's a lot of people interested in using 1:02:16.480 --> 1:02:18.840 things like ultrasound to better identify It's still a little 1:02:18.840 --> 1:02:21.360 bit tough right now, but there's certainly a lot of 1:02:21.400 --> 1:02:23.840 and there's also a ton of these different scores that 1:02:23.920 --> 1:02:27.680 people use, like laboratory values to try and say, if 1:02:27.720 --> 1:02:30.920 I'm not really sure, you know, should I call surgery 1:02:31.000 --> 1:02:33.960 or should I not there wasn't anything clear on imaging. 1:02:34.000 --> 1:02:36.240 There's like these scores that you can calculate to try 1:02:36.320 --> 1:02:40.600 and lean you more likely necrotizing versus not. None of 1:02:40.640 --> 1:02:42.360 them are perfect, but there's a lot of interest in 1:02:42.480 --> 1:02:44.880 like how do we better identify this early? And yet 1:02:44.920 --> 1:02:48.360 we're still seeing this increase in depths and without a 1:02:48.440 --> 1:02:50.800 corresponding increase in the mortality rates. And so I do 1:02:50.880 --> 1:02:53.440 think that this is due to an increase in cases 1:02:53.960 --> 1:02:57.160 from everything that I can tell. The other thing that 1:02:57.240 --> 1:02:59.760 we know there is an increase in is cases of 1:03:00.080 --> 1:03:05.960 Vibrio vulnificus, specifically these wound infections. Between nineteen eighty eight 1:03:06.040 --> 1:03:11.560 and twenty eighteen, Vibrio wound infections increased eightfold and also 1:03:11.840 --> 1:03:16.120 shifted northwards substantially. And we think that this is down 1:03:16.200 --> 1:03:20.800 to climate change change. Vibrio has actually, and this was 1:03:20.840 --> 1:03:23.280 a new fact for me, it's been called a microbial 1:03:23.360 --> 1:03:27.320 barometer of climate change because of how well it thrives 1:03:27.520 --> 1:03:30.640 in this warm brackish water and how highly sensitive it 1:03:30.760 --> 1:03:34.520 is to temperature. I've heard that, yeah, yeah, And so 1:03:34.640 --> 1:03:38.240 we when we combine all of this information plus the 1:03:38.280 --> 1:03:41.160 fact that we have an increasingly elderly population who are 1:03:41.480 --> 1:03:46.520 already at risk of necrotizing infections compared to younger populations. 1:03:47.520 --> 1:03:50.120 It's kind of a scary possibility that things could continue 1:03:50.200 --> 1:03:56.120 to increase vibrio and otherwise, but at this point, at 1:03:56.200 --> 1:03:57.000 least it is still rare. 1:03:57.080 --> 1:03:59.480 That's the only goodness. 1:04:00.560 --> 1:04:03.400 Yeah, Yeah, it's not really silver lining. 1:04:03.920 --> 1:04:06.640 Yeah, that's an acrotizing fasciitis sarin. 1:04:08.080 --> 1:04:16.439 Wow. I don't know how to react. I mean, there's 1:04:16.720 --> 1:04:19.520 I know, I it's horrifying. 1:04:20.120 --> 1:04:22.960 It's horrifying, and I it is a truly horrifying disease. 1:04:23.000 --> 1:04:24.840 And I also it's a it's a tough balance to 1:04:24.960 --> 1:04:28.360 not feel like like those headlines that are like I know, 1:04:28.640 --> 1:04:29.320 I know, you know. 1:04:31.120 --> 1:04:33.280 I mean I think, I think you're right, and I 1:04:33.320 --> 1:04:35.720 think it's like it's a hard balance because I think 1:04:35.760 --> 1:04:39.000 it's really important to be vigilant and like what what 1:04:39.200 --> 1:04:43.840 are things? How do we worry without worrying constantly? Like 1:04:43.920 --> 1:04:45.600 how do we worry about the right stuff? I don't 1:04:45.600 --> 1:04:48.440 know the answers to that me neither. Yeah, And I 1:04:48.520 --> 1:04:51.440 don't think the papers that we're about to guide you 1:04:51.520 --> 1:04:54.000 to will have the answers to that either. So, but 1:04:54.120 --> 1:04:59.640 they are great for reading or great transition so it 1:05:00.120 --> 1:05:03.520 I have a bunch I'm going to shout out too. 1:05:03.600 --> 1:05:07.919 In particular, one is by Louden published in nineteen ninety 1:05:07.960 --> 1:05:12.760 four in The Lancet titled Necrotizing Fasciitis Hospital Gangreen and Fhagiadina, 1:05:13.280 --> 1:05:16.520 and then another is by Quirk and Sternbach from nineteen 1:05:16.600 --> 1:05:19.160 ninety six. I was digging the nineties papers for this. 1:05:19.720 --> 1:05:21.280 I think there was a lot of interest, so a 1:05:21.360 --> 1:05:24.800 lot of papers, and this one was titled Joseph Jones 1:05:24.920 --> 1:05:28.800 Infection with Flesh Eating Bacteria from the Journal of Emergency Medicine. 1:05:30.840 --> 1:05:34.120 I had a bunch of papers, a few that I 1:05:34.280 --> 1:05:39.080 particularly enjoyed. I was a twenty seventeen was my year, Aaron, 1:05:39.360 --> 1:05:41.960 because one from Infectious Disease Clinics in North America from 1:05:42.000 --> 1:05:45.040 twenty seventeen was titled Evaluation and Management of Necrotizing soft 1:05:45.040 --> 1:05:49.400 Tissue Infections by Bonnie and Cadri And then another from 1:05:49.440 --> 1:05:52.160 twenty seventeen from the New England Journal of Medicine by 1:05:52.200 --> 1:05:56.200 Stevens and Bryant called Necrotizing seft tissue Infections. I had 1:05:56.240 --> 1:05:59.040 a bunch more, you know, from the last decades. 1:05:59.520 --> 1:06:01.360 You can find them all on our website. This podcast 1:06:01.360 --> 1:06:03.439 with kill you dot Com under the episode stab Yeah. 1:06:03.520 --> 1:06:03.960 Check it out. 1:06:05.120 --> 1:06:08.880 Thank you again, Maggie so much for sharing your story. 1:06:09.080 --> 1:06:11.520 I'm oh horrifying, harrowing. 1:06:12.240 --> 1:06:14.920 Yeah, thank you, thank you so much. We can't say 1:06:14.920 --> 1:06:15.280 it enough. 1:06:15.520 --> 1:06:17.840 Thank you to Bloodmobile for preventing the music for this 1:06:18.000 --> 1:06:19.800 episode and all of our episodes. 1:06:20.240 --> 1:06:23.120 Thank you to Leanna and Tom and Brent and Pete 1:06:23.280 --> 1:06:28.120 and Jessica and my everyone, everyone that's exactly right. 1:06:28.800 --> 1:06:29.080 Thank you. 1:06:29.600 --> 1:06:32.480 Thank you to everyone, and thank you to our listeners 1:06:32.760 --> 1:06:36.040 who are you know, make us or let us make 1:06:36.120 --> 1:06:40.280 this podcast. Words are failing me, And to our patrons 1:06:40.320 --> 1:06:43.320 whose support truly means the world to us. You are amazing. 1:06:43.520 --> 1:06:44.960 Thank you, thank you, thank you. 1:06:46.120 --> 1:06:46.320 Well. 1:06:46.680 --> 1:06:48.959 Until next time, wash your hands. 1:06:48.920 --> 1:06:49.840 You feel the animals. 1:07:02.560 --> 1:07:10.200 Um um um