Diagnosing and managing necrotizing fasciitis

On this episode of the CMAJ Podcast, Dr. Mojola Omole and Dr. Blair Bigham discuss necrotizing fasciitis, a diagnosis that can strike fear into the hearts of clinicians due to its rapid progression and devastating consequences. The discussion builds on insights from the CMAJ practice article, “Necrotizing soft tissue infections caused by invasive group A Streptococcus,” co-authored by Dr. Saswata Deb and Dr. Stephanie Mason.

Dr. Deb, an emergency physician and clinician scientist at Sunnybrook Health Sciences Centre in Toronto, outlines the key clinical signs of necrotizing fasciitis, including pain out of proportion to physical findings and rapid hemodynamic deterioration. He emphasizes the importance of considering NSTI in the differential diagnosis for cellulitis and the need for prompt surgical consultation when red flags arise. Crucially, Dr. Deb explains that no imaging or laboratory tests can definitively rule in or rule out the diagnosis—only surgical exploration can confirm it.

Dr. Mason, a burn and general surgeon at Sunnybrook’s Ross Tilley Burn Centre, provides a surgeon’s perspective on managing these infections. She addresses common missteps in diagnosis, the need for aggressive surgical debridement, and the role of multidisciplinary care in saving patients’ lives. She also discusses how surgeons can overcome their fear of creating extensive wounds, reassuring listeners that reconstruction is possible once the patient is stabilized.

Together, the guests and hosts explore practical solutions to reduce delays in care, including the potential for institutional protocols—possibly a "code nec fasc"—to streamline decision-making and improve outcomes.

For more information from our sponsor, go to md.ca/tax. 

Join us as we explore medical solutions that address the urgent need to change healthcare. Reach out to us about this or any episode you hear. Or tell us about something you'd like to hear on the leading Canadian medical podcast.

You can find Blair and Mojola on X @BlairBigham and @Drmojolaomole

X (in English): @CMAJ
X (en français): @JAMC
Facebook
Instagram: @CMAJ.ca

The CMAJ Podcast is produced by PodCraft Productions

Transcript

Dr. Blair Bigham:
I'm Blair Bigham

Dr. Mojola Omole:
I’m Mojola Omole. This is the CMAJ Podcast.

Dr. Blair Bigham:

All right Jola, today we are talking about something that scares the living daylights out of me. This is one of those cannot-miss diagnoses that emergency doctors, family doctors, surgeons—I think anybody in healthcare—is terrified to miss.

Dr. Mojola Omole:
Yes, we should all be terrified to miss it, but I don't mind nec fasc because it's like, if it's dead, we cut it. It's very straightforward. There's not a lot of thinking.

Dr. Blair Bigham:
How come everyone is so in a fuss about necrotizing fascitis? Every time there's a morbidity and mortality rounds in an ER, 50-50, it's a coin toss whether or not that rounds is going to be on nec fasc or on anything else in healthcare.

Dr. Mojola Omole:
I think that sometimes from the perspective of general surgery, especially some of us general surgeons who have done communities that we're used to, if it looks dead, we cut it out. But I do think for others, if you haven't seen a lot of it in your training and now is when you're seeing it, then it's a little bit more scarier because things go bad really, really fast.

Dr. Blair Bigham:
I think most physicians and surgeons worry a lot about nec fasc. So when Jola and I saw an article in CMAJ entitled Necrotizing soft tissue infections caused by invasive group A Streptococcus, we both said that is a slam dunk.

Dr. Mojola Omole:
And so we're going to be speaking to two of the core authors of that article. One is an emergency physician such like Blair, and the other is a surgeon. 

Dr. Blair Bigham:
Is a surgeon. Just like Jola.

Dr. Mojola Omole:
And together, like we do, we're going to walk through how to effectively manage in cases of invasive group A strep.

Dr. Blair Bigham:
And that's the key because I think in morbidity and mortality rounds, it's that lack of collaboration that usually gets a patient in the end.

All that's coming up next on the CMAJ podcast. We're going to walk through the critical aspects of recognizing, diagnosing, and treating necrotizing soft tissue infections caused by invasive group A strep with our panel.

Dr. Saswata Deb is an emergency physician and clinician scientist at Sunnybrook Health Sciences Center in Toronto. He's going to walk us through the journey of a patient from presentation at the ER to the handoff to surgery.

And Dr. Stephanie Mason is a burn and general surgeon from the Ross Tilley Burn Center, also at Sunnybrook. She's going to take us through the surgical management of these infections. Both of our guests are co-authors of the practice article in CMAJ titled Necrotizing soft tissue infections caused by invasive group A Streptococcus

Stephanie, thank you so much for joining us today.

Dr. Saswata Deb:

Thank you for having us.

Dr. Blair Bigham:

I'm sure I'll bring this up later, but I have been traumatized by group A strep infections as an emergency physician and an intensivist in patients who have both been managed maybe not optimally, and also in those who I thought we did everything right. And so I think our listeners are going to be on the edge of their seats to hear how we can do better for this group of patients. So let's just start at the beginning. Necrotizing soft tissue infections can be caused by either group a strep or by these polymicrobial infections with Clostridium perfringens, for example. Tell me how do these typically present?

Dr. Saswata Deb:

Yeah, so there's a textbook answer and there's the real life answer and…

Dr. Blair Bigham:

Let's go for real life. I feel like the textbook answer has led a lot of people down.

Dr. Saswata Deb:
I think that I could say the key takeaway message for this is that we have to think about it. It has to be part of the differential. These cases and these patients can present in a wide array of presentations. The most common presentation is being lots of pain that's out of proportion. And when that happens, we have to be very cautious about saying that this is just simple cellulitis. When there's lots of pain that just doesn't fit with the clinical picture, we have to think about this.

So to your question of how patients present, that's one of the most common things that kind of now sets a red alert for us. There are other things that patients may present with. So, for example, they could be sick, they could be hypotensive, they could have a fever. And the other part of it is that this can progress very rapidly.

And I say all of that, but I'll also tell you that they can also present with—there's nothing that you see in front of you, but they're just sick. And we've had patients like that where clinically there was nothing on a physical exam to say, oh my God, that area looks infected. However, they were quite sick from various other perspectives, biochemically and how they looked. Just because our center has seen so many of these cases, we were thinking about it and we were able to activate the right teams and get to this diagnosis.

So to your question, pain is a big thing. It's a big common sign. One of the physical findings is actually erythema. That's been reported as a very common finding. It's the later stages where the area may become purple or cyanotic, or it could be necrotic or hemorrhagic bullae, crepitus, decreased sensation.

But again, the absence of all of this does not mean that this patient does not have an NSTI. So these are things that we just have to keep in mind. Hypotensive, tachycardic, shock-like presentation is also something that we've seen in these patients. And the other interesting thing is that fever, which we would expect, is only present in about 40% of these patients. So the other 60% don't have fevers.

So, really it comes down to just having this diagnosis in your differential. And if someone presents with that classic cellulitis, some redness, some swelling, and their pain is out of keeping, think about it. And the other thing is that keep a close follow-up. So if someone presents with cellulitis, especially after we've seen so many patients, I always make sure that these patients are usually followed up in 24 to 48 hours to see how that area is progressing.

Dr. Blair Bigham:
I want to go back to that physical exam looking at the skin because we see a lot of people in the ER. Maybe they come in from a nursing home or they come in from the streets, and they come in with clearly a severe cellulitis. How can we, on clinical exam, say, well, wait a minute, this is more than severe cellulitis—this could actually be a necrotizing situation. Can we do that clinically, or do we have to look at other types of testing: laboratory testing, imaging testing?

Dr. Saswata Deb:
Yeah, you're right. There are certain wounds that look quite bad, but I think it's putting everything together. So again, if the wound looks bad and the patient's kind of sitting there laughing, it's one thing. But if the wound looks bad and the patient’s—again, the pain, pain, pain—and we're giving them multiple doses of narcotics, then that's a red flag for us.

And then if it's obvious with the other types of findings like the lesion that looks necrotic, it's crepitus, then obviously those are red flags. So in terms of physical findings, again, I will go back to saying that sometimes it is one of the biggest reasons that this diagnosis is often misdiagnosed or missed because sometimes it is not possible to tell just from physical findings, well, this is necrotizing soft tissue infection. So that's where we have to put the whole picture together with their hemodynamics, how they're looking, if they're presenting in a shock-like state. These are some of the things we have to put together.

We can use some other ancillary things like laboratory to help support this diagnosis. But again, if we're thinking about it, then really there's no other type of way to confirm this than to do a surgical kind of debridement and biopsy and exploration to confirm it.

Dr. Blair Bigham:
So let's get into the weeds here because as an emerg doc, I often feel obliged to either confirm or exclude something life threatening . So if I call an internist and say, I don't really think it's nec fasc, but keep an eye on it, I just want to admit it as cellulitis, the internist is going to give me a piece of their mind, right? That's not going to be a very collegial consult.

At the same time—and granted, I don't work in a tertiary care center—I will often call a surgeon and say, Hey, I think it might be nec fasc. And they say, Ah, it's probably not. Have you done any imaging? Have you done any labs? And so I feel obliged sometimes to try to prove it one way or another. And so I'll just send off labs, talk about the LRINEC score. I'll get a CT for reasons that probably aren't going to be helpful other than to falsely reassure somebody.

Talk to me about some of the benefits and pitfalls of additional testing beyond how painful is this and how bad does it look.

Dr. Saswata Deb:
Yeah. So I'll start off by just saying that there are no tests other than a surgical exploration that can confirm or negate this diagnosis when you're thinking about it. So to your point—and that's one of the reasons we wrote this paper—is exactly to clear that kind of misinformation from the various other specialties that you need imaging, you need certain blood work to confirm this.

No blood work, even if they came back normal, could confirm that this is not NSTI. Similarly, with CT scans, we know that the CT scans are quite specific, but they're not sensitive. So if the CTs come back normal, that does not mean that this patient does not have NSTI.

Dr. Blair Bigham:
Is that true for both nec fasc and necrotizing myositis, or a group A strep versus a polymicrobial? Is there any time where imaging is helpful?

Dr. Saswata Deb:
Imaging is helpful to support, not to rule out. It will tell you there's fascial enhancement, there's fascial edema, there's gas in the fascial layer. These are some of the things we can look for in the scans, and they support whatever you're thinking. That increases the fact that this is NSTI more. But if you're suspecting it and the CT comes back normal, that does not mean that this is not NSTI.

And if any specialty is saying—or any surgical specialty, and I'm sure Dr. Mason will speak about this—that they’re basing the ruling out of this based on a CT finding and report, that's just not sufficient.

The other thing I will add is that, in terms of the pitfalls, we are often waiting for CTs and MRIs. In our center, we're lucky—we have CTs available, we have MRIs available—but even then it's hard for us to get them on time. It's hard for us to quickly get them. And so I can only imagine that in a community hospital, where CT scanners or techs may not be available overnight, they have to be brought in, or in other hospitals where they may not even have a CT.

So there's now lots of good studies that have looked at this and have clearly stated that CTs may be supportive, but they should not be the end-all, be-all. Because when we try to order that, we're wasting critical time. And I look at this as: time is tissue. The more time we need to get a surgeon in. We need to have them explore and rule this out once and for all, and waiting for CT scans—and God forbid, MRIs—is just, it’s, I think, detrimental for the patient.

Dr. Blair Bigham:
I see Stephanie nodding there. Can the same be said for things like waiting on a CK, waiting on a sodium, waiting on a lactate—just not worth the wait?

Dr. Stephanie Mason:
So I think, Blair, one of the most important things you said is: are we waiting on a falsely reassuring CT scan? And that's what CTs are in this disease—they're falsely reassuring. So if you get a normal CT scan, and a necrotizing soft tissue infection has crossed your mind, if it’s crossed your mind,  then I think a surgeon needs to assess.

And I think as surgeons, we need to do a much better job of being willing to see and operate on these patients without a CT scan because I think we think that it gives us more information than the evidence tells us that it does. So if the CT scan gives you findings that are suggestive of necrotizing soft tissue infection, that's great. That gives us information. Most of the time it's going to be nonspecific, and we hang our hat on that thinking, oh great, now I can go back to sleep, I don't need to explore this patient.

But actually, a normal CT scan means you're no further ahead.

In terms of blood work, I think we're usually not waiting for blood work. Usually, by the time you've assessed the patient and thought about it, the blood work’s already back. I personally think a white count and a sodium are very helpful—they're the first things I ask what they are when I get consulted on one of these.

But I think you raised some good points that are more of the social aspects in the hospital to how we improve care for these patients. One of the things we've done at our hospital to try and get around the referral problem is to say that, if you as a consultant—number one, we ask that this be a staff-to-staff consult so that you directly call me to say, “Hey, I'm worried about this, I think it's a nec fasc.”

I then come see it myself, and I'm not allowed to say, order a CT scan and let me know when it's done. So those are some of the things that we've done to try and socialize this idea of time is directly proportional to mortality here, and we're wasting time.

But when you call me, I'm going to say, “Hey, what's the sodium and what's the white count?”  Because a sodium less than 135 and a white blood cell count greater than 15 together are very, very suggestive of the diagnosis. And in almost all of those patients, I'll be bringing them to the operating room.

Dr. Blair Bigham:
With a normal CT, a normal lactate, a normal CK, a normal blood pressure. You're still interested.

Dr. Stephanie Mason:
I'm still interested.

Dr. Blair Bigham:
Okay. 

Dr. Stephanie Mason:
And everyone else listening should be.

Dr. Blair Bigham:
Tell me about some of the misnomers. I mean, I'm sure you've arrived and you've said, this person should have been in front of me hours ago, days ago. What are some of the other misnomers that can be falsely reassuring?

Dr. Stephanie Mason:
I think CT is the main one that's falsely reassuring. I think the other thing that's falsely reassuring is that we all learned in medical school that these patients are going to have crepitus. And I've noticed a lot of the time when I've gotten involved later than might've been ideal that there was this—it's documented everywhere—"no crepitus, no crepitus, no crepitus," as if we think that this is a really telltale thing.

But they've actually done quite a few studies now looking at the most common signs and symptoms, and crepitus is present less than a third of the time. So it's not this pathognomonic feature that we were taught in medical school, that it is, that's on our board exams, and so on.

And so the reality is, it's a much more subtle diagnosis to make. Almost nothing should be reassuring, really, once it's crossed your mind, other than directly exploring it.

Dr. Blair Bigham:
Okay. So we've established that if it crosses your mind, if you're looking at someone going, that doesn't look right, this story's concerning, there's pain out of proportion, it looks gnarly, the patient has unstable vitals—whatever it is that's brought nec fasc to front of mind or a necrotizing soft tissue infection to front of mind—we're calling a surgeon.

Ada, before we move on to the surgical management, just give us the top three or four things that we need to get started while we wait for that surgeon to arrive.

Dr. Saswata Deb:
Ya so number one is resuscitation. So we need to make sure we're resuscitating a patient. We can't forget that. So whether they need fluids, whether they need pressors, we need to start that.

We need to start them on antibiotics—so broad spectrum as well as some exotoxin-dressing antibiotics. So Piptaz broad spectrum and clindamycin are often the two antibiotics I go to. And then, depending on if I think that the patient may be at high risk for MRSA, we would add on some other agents.

So top three things: resuscitate, antibiotics, and get on the phone.

Dr. Blair Bigham:
Okay. I want to get into some surgical questions. I'm going to play hardball with you, Stephanie, because as a community emergency physician, I have had to make dozens of phone calls to get a surgeon to see a patient who I think has nec fasc. Let's start with this: which surgeon am I calling? Because it seems to be very different in certain places. Is there any type of rule about who you call if you think the nec fasc is on the belly versus in the groin versus on the leg?

Dr. Stephanie Mason:
Yeah, it's a good question, and it's very hospital specific. So at our hospital, we have consult guidelines for necrotizing soft tissue infections that depend on the body region. So, for example, the face goes to plastics, upper extremity goes to plastics, lower extremity goes to ortho, torso goes to general surgery, Fournier’s goes to urology, for example.

So there's a specific policy for your organization, great—follow that. I would suggest that one of the things we can do to overcome some of the barriers to getting these patients quicker care is that having some sort of policy like that to guide you so you don't have to figure it out when one patient is sitting in front of you can be very helpful.

Often, I would say based on the cases I see, the first person to touch the patient after emerg is usually general surgery or plastic surgery. And sometimes it's ortho on the extremities. And in some places, it's actually vascular surgery on the extremities.

But I would say if you don't have a policy, it's a good thing to think about. That's a really easy, low-hanging fruit way to do some quality improvement around this as a process. But otherwise, it's often general surgery I think that in community hospitals might be the first touchpoint.

Dr. Blair Bigham:
It seems like every emergency department—one in two M&M rounds is for a nec fasc. It just seems so common that it's either missed or it's captured but it”s enacted upon not quickly enough. And I think emerg docs and surgeons share that responsibility.

I love this idea of having a corporate policy or a site policy around how you handle this. How can emerg docs address  on the phone, like, what are the magic words to say when a surgeon says, "Hey, can you do additional testing and call me back?" or, "Oh, I don't really do this type of surgery. I know it's my part of the body, but this could be extensive. I'm not comfortable. Can you call someone else?"

What is the collegial way to raise the flag that, no, I need a surgeon to come to the bedside? And I say this with this personal story where I called four different surgeons for this Fournier’s leg, abdominal wall type of nec fasc, and I called all four. I said, all of you need to come to the bedside. They all did after some coaxing. And all of them denied responsibility.

And I don't say that to embarrass anybody, I just say that there seems to be a bit of fear about going to the operating room with these. Where's the miscommunication?

Dr. Stephanie Mason:
There definitely is. So I think there definitely is, and that's why we're really happy to even be having this conversation because I think the reality, whether we like it or not, is that this is not as rare as it once was.

Number one. I think a lot of the fear comes from not wanting to be the person that has to guide the care, because the debridement that's required, I think, is not an operation that anyone is specifically trained to do—short of probably burn surgeons—and there’s not very many burn surgeons around.

So debriding soft tissue is not an operation, this is not an operation you'll find in any textbook. It's not a described operation that everyone was taught and learned how to do. Depending on where you trained, you may or may not have ever seen this done.

But in talking to my colleagues and talking to people who refer these patients to me, I've learned a few things. And I think the uniting theme or concept is that it's not so much fear of debriding, it's fear, or not having a level of comfort with what would be reconstructible. So, how big of a hole can I make and how do I get that patient out of the hole after I make it?

Dr. Blair Bigham:
Oh, okay.

Dr. Stephanie Mason:
And I think that's where a lot of the fear comes from. Whereas I'm a burn surgeon, I routinely admit patients who have lost more than 80% of their skin on their body, and I can debride that and I can get them out of hospital. So making big soft tissue defects doesn't scare me, but I know it scares everybody else.

And so I think that's part of it. It's like, how can you possibly survive if I cut your whole flank off? And so I think that's part of it. I think the reality is necrotizing soft tissue infections—the care ultimately needs to be multidisciplinary. There are lots of us out there with the expertise to reconstruct these wounds. You can refer the patients with the big defects to a burn center. That’s what we, we reconstruct them.

We don’t do the acute care of them; we do the reconstruction, but there needs to be a patient there to reconstruct. And if we don't convince surgeons to take this on, do the aggressive debridement—that’s what’s going to save the patient’s life. I can put them back together again after. But I think we need to get that message out there more: that very extensive wounds can be reconstructed, and the care for that exists.

And that care doesn’t have to happen at your hospital. That care doesn’t have to happen in your hands, but I need you to do the debridement first.

Dr. Blair Bigham:
So step one is be brave, be badass, and just chop away that tissue.

Dr. Stephanie Mason:
Just cut the dead tissue away. Everyone can use a pair of scissors, and honestly, fancy equipment is not required for this. I do this with a pair of heavy curved scissors, and the vast majority of the debridement can be done that way. And that will save a patient’s life.

We all learned how to use a pair of scissors in residency—some of us even before that—and we'll be there on the other side. There's help on the other side; there's support on the other side. But somebody has to take ownership of it and just get them to the operating room.

And so one of the things that we say is: this started on the abdomen, but it's also on the thigh. So you know what, whoever you called first—tag, you're it. I called you, this patient needs care. The sooner we get them to the operating room, the better.

Can you please take care of it and then call your colleague in orthopedics? Let’s make this a teamwork thing. But somebody has to take charge because what we've realized from reviewing a lot of the cases where something’s gone wrong is that everyone thought they were involved but didn’t think they were the boss.

It’s like, oh, I thought you were booking the case. Oh, I thought we were following. Oh, I thought you were going to follow up on the blood work. Somebody needs to take charge.

There definitely should never be someone in the middle of the night doing this all by themselves, but somebody has to take charge and take the patient to the operating room—and then phone friends. And those friends need to come.

We need to just be collegial as a group, recognize that these are tough cases, that we’ll do them together so that we can save the patient’s life.

In an ideal world—you asked me what the magic words are—I think the magic words should be: you say nec fasc, I say coming.

Dr. Blair Bigham:
Right? Okay. How often do you take someone to the operating room and within five seconds you go, oh, this isn't nec fasc, we're done? Does that happen a lot? Are there sort of false positives?

Dr. Stephanie Mason:
It doesn't happen very often, and I am glad you brought that up. I think it should happen more because the fact that it doesn't happen very often means we don't take enough of these to the operating room to explore them.

And I think as a group of surgeons, we should be a lot more comfortable doing a negative exploration for this. We do negative laparotomies for trauma, for instance, and for other things. We should be a lot more comfortable saying, "Hey, I made a little cut. Everything looked fine. Now I can very confidently tell my colleagues I don't think this is nec fasc. I've explored it. Figure out what else is going on,” you know, in a Shock NYD case or something like that.

And so I think there should be more of them where we do that. And you don't need to take the patient to the operating room and make a massive defect to determine that it's not nec fasc. You can do a small cutdown. It just needs to be the size of your finger to allow you to assess the integrity of the underlying tissues.

And the very easy way to do that is you do it at the bedside. All you need is a scalpel and some local anesthetic. Depending, if the patient's awake and stable, maybe you help out by coming and doing a little bit of sedation for us to facilitate the procedure. You make a very small incision, just enough to be able to put your finger in and probe the wound.

And if you put your finger in and it's not smelly, no gross fluid comes out, and the tissue planes seem intact, then great. You've ruled out a necrotizing soft tissue infection.

Dr. Blair Bigham:
Why are these infections on the rise? Why is this becoming more common?

Dr. Stephanie Mason:
The short answer is we don't know. Our infectious disease colleagues have some interesting data showing the epidemiology of group A strep in the province, and it's just skyrocketed. And they don't know exactly why. They do have some theories.

I think part of the reason why necrotizing soft tissue infections in general have gotten more common is that I think medicine has gotten a lot better, and people are surviving a lot of different conditions, different operations, and we just have more sick people around. So more complications are going to occur among those patients.

We have patients on immunosuppressives or chronic antibiotics, and that changes their resistance patterns and things like this. So I think that's part of it.

I think we also are better at recognizing what these infections are. So I'm not convinced that they’re, group A strep, for sure, is an epidemiological phenomenon has increased. But I wonder whether these infections have actually increased, or if we've just gotten better at recognizing them. And whether there were patients dying and we didn’t know why they were dying.

So I'm not sure. But I think in general, at least at our hospital, we're taking care of patients who are much sicker with much more comorbidities, and I think that's part of why we're seeing more of them here.

Dr. Blair Bigham:
I want to reorient us to some solutions as we come to a close here. Can you tell me about your experience building this sort of local policy, team alert system, and working on the culture to really expedite care? What have you seen change since that came about?

Dr. Saswata Deb:
I can tell you that at the level where when we are seeing patients, and because of this excellent, robust policy that we have, I think the guards have come down in terms of we don't have to be a hundred percent sure that, oh my God, this is necrotizing fasciitis or NSTI. We can, if we're suspecting it, we've created a culture where we can call the corresponding area that we feel is necessary to come and assess this patient. And there's no roadblocks because we're all in the same mental model in terms of how serious this is. And these patients that we've had have been quite sick where our two phone calls are to the corresponding surgeon and to the ICU. And with these policies in place, there's no questions of, hey, can we get a scan first? Can we do this blood work first or X, Y, and Z?

The staff comes down, and within 30 minutes, when the staff comes down and they feel that maybe it's not their area, someone else needs to get involved, and then they make the next call, and that person comes within 30 minutes. And if there's any confusion, we always have our burn center as a backup to guide us with this.

Dr. Blair Bigham:
Stephanie, last word to you. What's your plea to physicians and surgeons out there?

Dr. Stephanie Mason:
My plea to all physicians out there is to have this on their differential, then to call a surgeon. And my plea to surgeons is to take that call, take it seriously, and come assess the patient. And if there's any doubt whatsoever, cut into it. Cut into it in the emergency department, that's fine, cut into it in the ICU, and if you cut into it and you're worried, then bring the patient to the operating room. But ultimately, we need to get these patients into the operating room, and I can reassure everyone, make the cut first. Let a burn surgeon or your plastics come and decide what's reconstructible later. But if you don't, we don't have time to make that decision upfront. So just debride what's clearly necrotic, get rid of that, and then call for help. But we need to do the first part to give the patient a chance.

Dr. Blair Bigham:
Thank you so much, both of you. This has been an excellent conversation, and I'm so glad that we're able to highlight this. Thank you for choosing this as a topic to write about. I think it's going to bring a lot of clarity to those of us in the field who are just so terrified by this diagnosis, whether we miss it or catch it, it's scary. So thank you so much for joining us.

Dr. Saswata Deb:
Thank you, Blair.

Dr. Stephanie Mason:
Don't be terrified. 

Dr. Blair Bigham:

Dr. Saswata Deb is an emergency physician and clinician scientist, and Dr. Stephanie Mason is a burn surgeon and general surgeon, both from Sunnybrook Health Sciences Center in Toronto. Okay, Jola, I hogged all of Stephanie's time. I want to throw it to you. What's your take as a surgeon?

Dr. Mojola Omole:
For me, as I was listening, what really stuck out to me was what it really boils down to at the beginning is that turf war of who's supposed to do this, who's not doing this? And Stephanie made some really great points that it is people's being uncomfortable with hurting or taking out something they're not supposed to take out. I've never felt it that way. I always felt like if it's not alive, then it has to go. So that's what we need to do.

So I think maybe it's creating a more supportive environment for our other colleagues who don't feel as comfortable to have that bravery, as you said, to be a bit of a badass and to just go in there. And then the other thing that I never knew about was that the sodium, less than 130.

Dr. Blair Bigham:
Oh, the low sodium. Yeah.

Dr. Mojola Omole:
You knew about that.

Dr. Blair Bigham:
Well, they make us memorize it for the Royal College exam. But then again, if their sodium's normal, what are you going to do? Walk away?

Dr. Mojola Omole:
But I do think though, because there's always, is it nec fasc or is it not? And it's that conversation of, okay, is the sodium low? Is the white count high? Yes.

Dr. Blair Bigham:
But what about the logistics? None of these on their own or even as a constellation are necessarily good enough to rule in.

Dr. Mojola Omole:
I do cutdowns. I've done them in, I was lucky we were in ICU. The ICU doc was able to give some ketamine, 

Dr. Blair Bigham:
Oh you just do it at the bedside.

Dr. Mojola Omole:
Yeah, and so I do…

Dr. Blair Bigham:
So you don't have to go to the OR. You could just come down to the ER and do it.

Dr. Mojola Omole:
And I do think that part, we both work at the same institution, and that what we probably do need to institute is that there's a policy. If we think it's nec fasc, we do the cutdown right there and then to sort out if it's nec fasc or not.

Dr. Blair Bigham:
I love this idea of an institutional approach, right? We have a code STEMI, we have a code blue, we have a code stroke. We could have a, I dunno, a code nec fasc, a code sepsis, where people come running and they say, okay, how about we all just stand here and be confident one way or another so that nobody has to fret over this? So that an emerg doc doesn't lose sleep at night about, oh my goodness, what if that was nec fasc? Or an internist isn't like, I don't know if I should admit a surgical emergency to a medical ward. Just have everybody who's involved in this decision-making come to the bedside, and Jola, then we could just know, right? In our heart, we've all agreed one way or another—whether we've cut down, we've not cut down, we've come up with a plan, and then this person doesn't just linger and get found with this horribly purple leg six hours later.

Dr. Mojola Omole:
And it's just to say, okay, whatever services think that manages it at that institution, you come to emerg. The emerg physician knows that they're responsible for the conscious sedation, and we do a cutdown, and we know right away, this is nec fasc. Really, she's right. It's literally a finger. I've done two fingers, and then we just closed it up with three nylons, and literally,  took us—we did one, we did the belly, we did the thigh, two sides of the thigh, and it took us maybe half an hour.

Dr. Blair Bigham:
Well, I guess you and I are now the steering committee for the nec fasc response at Scarborough Health.

Dr. Mojola Omole:
It seems like it.

Dr. Blair Bigham:
Hopefully, other people take up the challenge and help get this sorted out once and for all. Yeah, it sounds like—I know I certainly have—it sounds like Stephanie and you have as well had people who die from nec fasc.

Dr. Mojola Omole:
For sure. A hundred percent.

Dr. Blair Bigham:
This type of coordinated attack seems necessary.

Dr. Mojola Omole:
And I do think that someone will not mind having a cut on them to find out if this is a deeper infection versus just a soft tissue infection, a cellulitis, and they would be grateful to be alive. It's also very reassuring when Stephanie says, we transfer out to bigger centers when we need to do reconstruction, and we need to feel comfortable with that.

Dr. Blair Bigham:
As a non-surgeon, I definitely have to say, I don't appreciate two weeks from now or four weeks from now, how are you going to reconstruct this? How are you going to close this? I never think about that when I'm like, I think this should go to the operating room.

Dr. Mojola Omole:
Well, I mean, the easier thing for me as a non-plastic reconstruction surgeon is I don't worry about it either. It's not for me to worry about.

Dr. Blair Bigham:
Right. We can always call for help later if the patient is still alive.

Dr. Mojola Omole:
Yes, because you can only fix and reconstruct an alive patient, not a dead patient.

Dr. Blair Bigham:
That's it for this episode of the CMAJ Podcast. If you like what you heard, please give us a bump, let people know about our podcast so that we can help spread the message. The CMAJ Podcast is produced for CMAJ by PodCraft Productions. Thanks so much for listening. I'm Blair Bigham.

Dr. Mojola Omole:
I'm Mojola Omole. Until next time, be well.