In Bill's words

Bill's Email address: william.obremskey@Vanderbilt.Edu

This will be the last entry into the Bill Obremskey/update/ blog as it is my thoughts and musings on the last 3 to 4 weeks of my life. It may also give others a clearer picture of what occurred. I feel a little as if this is like Jeopardy or starting a joke with the punch line as you all know the outcome of this saga. Anyway, I will try to fill in some of the details and give my early thoughts.

On Monday, June 8, I was “on call” after working on the weekend June 6 and 7. I received a call at approximately 7 a.m. after we had finished our morning rounds to assist Dr. May with an operation. I was a little concerned, as it is highly unusual to be asked to assist another surgeon and Dr. May is a personal friend as well as colleague and so I promptly went to see what help was needed.

Dr. May was attempting to save the life of a man who had developed what is commonly known in lay press as “flesh eating bacteria” and “toxic shock syndrome.” This gentleman had received a deep bruise to both thighs 3 days previously as he is a heavy construction work when a cinder block fell and as he was catching it hit his legs. Group A strep is a common bacteria in the environment on most people’s skin but it can occasionally become an active infection in people who have closed injuries. A common access point for the bacteria is through small cuts in feet such as with athlete’s feet or people with diabetes. This gentleman had diabetes, and his infection was unfortunately rampantly spreading through his left and his right leg. On attempting to remove all the deep tissue from his left leg it was noted that the entire leg was dead and Dr. May and I proceeded to remove his entire left leg. Unfortunately during the process I was stuck in the left long finger with a needle. I followed hospital policy and removed my gloves, cleaned the area and was able to scrub back in and complete the operation. The patient was checked for other diseases such as HIV and hepatitis C, as was I, and neither one of us had evidence of these common blood-borne diseases. These blood-borne diseases are routinely checked because they are very difficult to treat. The patient had Group A strep and necrotizing fasciitis and toxic shock syndrome. Unfortunately this man succumbed to his severe infection in the next week. The entire next week for me was fairly routine. My needle stick on my left hand appeared to be healing without significant incidence and had a regular operating room day on Monday, June 15. In retrospect, I think that during the operation on the patient with the severe leg infection that some of his blood spilled down onto my shoes and over the next week harbored and grew in my shoes. On Monday, June 15, due to a chronic 30-year history of athlete’s feet the infection probably spread to my right foot through blood-soaked shoes. Tuesday, June 16, I spent the afternoon on Percy Priest Lake with Allie and a group of teenagers in celebration of her upcoming 16th birthday. We water skied and knee-boarded and had a wonderful afternoon of fun. That evening I played tennis with a group at the country club. After that I felt incredibly tired and fatigued and went home and went immediately to bed. Jill was working that night but I checked on the kids and they were all doing well and they got themselves in bed. I woke up Wednesday feeling achy and sore like I had an early viral illness. I did not have very many operations to do and they were not to difficult and went and spent the day operating.

As I recently learned it was not such an easy day, as one of our nurse practitioners took several pictures of me in the surgeon’s lounge laid out sleeping between operations as I was beginning to be taxed by the infection invading my body. Again, I got home and went almost immediately to bed feeling I was just developing a summer cold and/or flu. Thursday morning I woke up after a restless night of sore back, achiness and feeling a little feverish and realized I was not well and immediately began to make phone calls to tell people at the hospital that I would need to be cancelling the clinic as I usually see patients in our office on Thursdays. By noon that day I really did not feel very well. I thought there was some redness in my foot and I noticed some new swelling on the right medial thigh. I called the surgeon’s office who did my right hip replacement as I was somewhat concerned about the possibility of development of a deep infection of my right hip and realized I needed to be very concerned about an infection there. I realized I was not feeling well at all and called the hospital. I asked one of our residents and one of my partners to see me. I arrived at Vanderbilt, had some blood work done, as well as x-rays of my right hip and an MRI of my right hip to see if there was any fluid around the right hip which would be an indication of infection in the right hip. Luckily there was no fluid in the right hip but there was inflammation in lymph nodes of my right groin and knee and the redness had progressed in my foot and thigh. After talking with my colleague and one of our infectious disease colleagues we had decided to admit me to the hospital and start IV antibiotics assuming this was an early cellulitis (infection of the skin) or lymphangitis (infection of the skin spreading up the leg in the lymph nodes).

Unfortunately, this was essentially the end of my conscious memory. By Friday morning, apparently I was somewhat confused and not feeling well but still not critically ill. Jill brought Analise by the hospital to tell me good-bye as she was leaving for camp that day. Jill also began a long series of good strong decisions by asking our good friend, Addison May, to come take a look at me as she was worried about how I was acting and how I felt. Addison saw me and immediately realized that I was not well as the infection was beginning to go through my body (sepsis)and I needed to be moved to a more closely monitored part of the hospital and as he is in charge of the surgical intensive care unit made arrangements for me to be transferred to the surgical intensive care unit (SICU). Friday and early Saturday were somewhat up and down events. As my body and the antibiotics were attempting to fight the infection and sometimes I seemed to be doing better and other times worse. By Saturday afternoon the overall trend seemed to be bad and Dr. May decided to take me to the operating room. When he did that he found that the infection was throughout my foot and traveled up the lymph nodes behind my knee into my medial groin. He felt the diagnosis at that time was “necrotizing fasciitis” and was developing “toxic shock syndrome.” Toxic shock syndrome is when the toxins released by the bacteria begin to affect other organ systems such as your kidneys, liver, lungs, heart. Dr. May attempted to clean out the infection in my leg on Saturday night and then again on Sunday morning and yet again on Monday. These 48 hours were the times when I was the most critically ill.



I asked Addison recently how ill I actually was. He told me he felt that if there had been a delay in moving me the SICU that it would have been too late to resuscitate (provide fluid, oxygen, medication) and if surgery had been delayed 2 to 3 more hours on Saturday that we might not be having this conversation. This is the time period when the family started to develop the blog to keep friends and family updated on my condition. This is also when Addison May started having twice daily family meetings and when Jill demonstrated incredible strength and intellect in leading the family meetings and approaching every issue in very factual and structured basis to try to make good decisions. During these 48 hours I at times was not doing well. One of my favorite quotes from another colleague, Dr. Patty Wright (an Infectious Disease specialist), who said “Bill, we were ready to try anything to make you better including spreading mayonnaise all over you.” Just for the record, they elected not to attempt mayonnaise but our Vanderbilt Chief of Staff, Dr. Allen Kaiser, approached Addison with a novel idea to consider a high dose steroid treatment (decadron) for 2 days to try to blunt the effect of the toxins effect on my kidneys, lungs, liver and heart, and to give my body and the antibiotics some space and time to begin to fight back. He had done some work with toxic shock syndrome patients 20 years previously and had felt it at times had been “a light switch” that allowed patients to begin improving. Addison May consulted with some colleagues about the idea and decided with Jill to use the steroids on Sunday. It is unclear but this seemed to be the timing that allowed me to begin to turn around. On Monday during surgery Dr. May felt the disease and infection had not progressed further and that we were beginning to make progress in staying ahead of the infection. By Tuesday I was improving. They attempted to remove the breathing tube but after a short period of it being out I was tiring out and it was reinserted. The breathing tube eventually was removed on Wednesday evening and this is when my conscious memories began to return.

Apparently a stream of family and friends came during these several days as well. I and my family were overwhelmed by the show of love and support from cards and letters and comments on the blog. I thank all for their kindness, thoughtfulness and empathy showed to myself and my family.

I remained in the surgical intensive care unit for the next 48 hours and this was some of the most challenging time for myself, as it is a time of partial consciousness, delusions, hallucinations which is a fascinating experience I care never to repeat again. The medication,, sleep deprivation altered sensorium for whatever reason and I went into a long series of hallucinations, delusions which I knew were hallucinations and delusions but I could not make them go away unless I intentionally did something, so I would frequently sit up and look around in the intensive care unit and this would make the cobwebs clear momentarily but then I would essentially slide back into partial consciousness attempting to fight the “demons of delusions.” My most vivid delusion was that Nick had returned in the middle of the night from my sister’s house in Jacksonville, Florida where he had gone to help entertain her 3 boys as well as remove him from the acuity of the situation. To this day I have a very distinct memory of him giving me an Ipod player to use and listen to in the intensive care unit and I gave him a credit card and told him to go catch a cab to home and wait until morning and then return to Jacksonville with his Aunt Kate.

The memory is so vivid that I could not find the Ipod player in my bedding as my bedding had been changed and I asked the nurses several times to go through the linen to find Nick’s Ipod which he had made such an effort to give me. Many of these experiences and understanding will help me to be a more empathetic and compassionate physician with patients in situations that have significantly altered their lives.

I left the surgical intensive care unit on Friday, June 26, and continued to improve daily until I was able to be discharged on Monday, June 29. Leaving Vanderbilt Hospital was a great experience and sense of freedom and relief.

In the 20 years I have been educated and practicing medicine, myself and a number of colleagues have taken care of several people with this Group A strep that then developed necrotizing fasciitis and toxic shock syndrome. The consensus of our experiences is that approximately 80% of patients do not survive this episode and those that do survive are missing parts of limbs. I left with several wounds on my foot from where the infection was drained as well as a wound that extends from the back of my knee to my medial thigh that is partially open with a drain constantly trying to shrink the area but overall my muscles, nerves and long-term leg function should be essentially normal. I lost approximately 10 pounds and I do not recommend this as a technique for weight loss but it certainly was effective. I have been home 5 days now and feel I have doubled my improvement essentially every day in terms of my stamina and ability to walk independently. I saw Dr. May in his followup clinic today. My wound is still open on my leg but we plan on closing it on July 6, Monday, and hopefully that will be my last operation and surgical episode with this illness.

From the moment I regained consciousness I had several thoughts or musings. It was incredibly clear to me that it is important to have a purpose and meaningful life. How each one of us decides to find that I think is our own personal decision. To pursue that meaningful life, I also felt that several other things were critically important to me for this encore part of my life.
#1 – Stay healthy, have a strong heart and stay alive. There is no doubt in my mind that my body would not have survived this without being in pretty good physical condition and having a strong heart. It is too easy to get out of shape and the long-term consequences of that can be deadly.
#2 – Hug your spouse, children and loved ones daily because you never know when you may not see them again. A friend of mine, John Shoenecker, suggested I should hug my dog as well. Being a dog lover I wholeheartedly agree with this. I also believe we should attempt to hug and love those around us as our dogs love us: unconditionally, constantly, at times frenetically. They also love us even when we forget to feed them or give them water and are never grumpy or cross with us. So, love your loved ones as your dog would love you.
#3 – Try to do a little good in the world everyday one person or patient at a time.
#4 – Try to look at life as half full as I have learned it can always get worse and while looking at it half full hopefully you take the time to enjoy some half full cups of red wine, enjoy a few sunsets and enjoy the journey of your meaningful life.