A Near Thing

My lower left leg and foot - cellulitis

I feel well enough to say that at long last I have finally turned the corner on my recent brush with death. It is strange reading the last entry in this blog, at the end of March 2013, because of the allusion to our general well-being. Little did I realise that I was about to be hospitalised a few days later.

Never spent a night in a hospital in my entire life until this; I was even born at home. The diagnosis was  cellulitis in the left leg which had ballooned in the course of a few days and was horribly discoloured and looked truly hideous plus I had fever. So I was admitted to The Riverside Hospital in Bacolod City. Looking back I am glad I got to hospital when I did as it might have been even more serious had I waited any longer.

Cellulitis is a serious subcutaneous, bacterial infection of soft tissue, no relationship as far as I know to the common female complaints relating to cellulite! The above shot says it all. How did I get it? Not really sure. The most likely scenario is that it came from an untreated small cut on the sole of my foot sustained birdwatching on the mudflats near Sum-ag. However it could have been an insect bite or some other unknown cause. A week earlier I went to hospital as I was feeling a bit under the weather and showed the doctor my foot and explained what had happened. The doctors were non-commital and more concerned about high blood pressure. Paracetamol and rest was ordered.

Fortunately intravenous antibiotics brought the infection under control and my fever went after a few days. However, the doctors proposed debridement, a form of surgical cleaning, as a more aggressive means of removing the external signs of the infection. I agreed to this and had a first ever surgical procedure with a general anaesthetic. In retrospect this was really a superficial debridement, a sort of scrape of the surface of the affected areas. The surgeon expressed satisfaction with the results and after a week or so I was adjudged to be well enough for discharge. I was left with a wound on my left instep running from the ankle bone but the surgeon assured me this would heal in time.

Over the next couple of weeks my left leg healed well but my left foot didn't and it produced a fair amount of discharge. I can't confess to having been a good patient either as I picked at the scab. I continued to see the surgeon, however, and he seemed pleased with progress. We returned to Thailand at the end of our scheduled holiday. On a hunch I decided to consult a local doctor in Ratchaburi on our return at the end of April. I just didn't feel happy about my foot. He didn't mess around - he told me to proceed immediately to the hospital as he believed I had Necrotising Fasciitis ("NF"). The good doctor didn't even charge me for the consultation.

So I was admitted to Ratchaburi Hospital that same night. I was fairly anxious as I knew NF was a potentially fatal infection. In short it is a soft tissue bacterial infection, a type of gangrene, spreading dead cells;  it is virulent and powerful and as well as intravenous antibiotics, surgery is required to remove the dead cells.

I was seen that evening by an intern; he said there were two options: hook me up to antibiotics and observe me for three days or proceed with debridement. I asked him when he proposed to carry out the debridement and he replied "This evening", which was not what I was expecting! So after a brief discussion with Luna I decided to go for debridement on the basis that time was of the essence.

Over the next five days I had a further two debridements which were wholly different in character from what I had undergone in The Philippines; they really went in deep. I remember seeing a deep dark cavity in my left instep when they opened the dressing three days after the final debridement. How will they ever close this, I remember thinking.

However I was surprised when the doctor told me I could go home for a few days; he advised that all the dead, infected cells had been excised but that they would need to wait for a few days just to be sure that the had got rid of the infection; then they would perform a skin graft. I was delirious to be able to go home and also to be getting better.

By this time I had checked out NF online and was very aware of what a serious matter it was with a 30% fatality rate - that was far too high for my comfort! I would strongly advise you to desist from researching your ailments online while in hospital - it really is scary. My Thai fellow patients have a much more sensible approach; they come in, sleep, get treated, convalesce and go home and they do not appear to ask any questions.

A few days later I went back to hospital and the doctor confirmed the wound was clear of infection; I was surprised to see that the cavity was full of new tissue. I was also delighted to be free of the infection. So the following day I was taken to theatre for a skin graft. As is usually the case following the procedure, the skin graft site was more painful than the wound site. I was confined to my bed for ten days with my foot in a plaster cast, a terribly frustrating experience.

Alas when the dressing and plaster cast were finally removed the skin graft had only partially taken. I was given the option of a further skin graft or to allow the wound to heal naturally. After consideration I opted for the latter. My heart rate and blood pressure had gone through the roof while in hospital and I was very fearful about the consequences of a further surgical procedure and general anaesthetic. A week later I was discharged with instructions for the wound to be dressed every three days. This takes us to the end of May.

The first occasion I had the wound dressed was a nightmare - I went to an external clinic, part of the hospital, where a nurse scraped the wound with a metal instrument. I didn't like the look of the wound either. So I proceeded immediately to the main hospital and was re-admitted through the emergency room. The staff there were concerned about re-infection and given my recent history didn't want to take any chances.

So another ten days in hospital on intravenous antibiotics. I had a major scare when a lab culture report indicated traces of bacteria known as "A. baum" or acinetobacter baumanii; check this bacteria out on google if you want to scare yourself shitless, which is exactly what I did and how I made myself feel! A blood test, however, revealed, the bacteria had not got into my bloodstream and so normal dressing and cleaning of the wound solved the problem. Subsequent pathology reports indicated no growth. Phew! I was finally discharged on 10th June 2013.

On discharge I decided to attend a different hospital for wound cleaning and dressing. I went to Muang Ratch hospital, a local private hospital and I must say it made a big difference. The doctor there, Dr Ananch, recommended daily cleaning and dressing which he supervised; indeed he inspected the wound every day.

There have been a couple of setbacks requiring precautionary antibiotics. Basically there is no skin over the wound area by virtue of the failure of the skin graft. The medics have advised that the wound will nevertheless close and form a scar. To date this has been a slow process. A small part of the wound has opened twice. However over the last few days the wound has fully closed and it feels wholly different in character. I still get some inflammation and swelling, depending on activity, but much less than, say, a month ago.

It would be hard to convey the range of emotions and feelings that I have experienced over the last few months. Luna, my wife, has been a tower of strength and she has coped brilliantly with all the pressures and demands that suddenly fell on her; special thanks to Mark, a teaching colleague, who drove for Luna during my hospitalisation and incapacity and enabled her life to proceed as normally as possible. I've always felt confident about our relationship and hope I can reciprocate if the roles are ever reversed. This experience served to underline something of the sacred mystery of marriage that the Bishop of Ratchaburi talked about when he married us five years ago.

My sister Katherine in Scotland was a great source of support, phoning virtually every day and even threatening to come out; likewise my friend Tony from Scotland made regular phone calls and emails. Many other relatives and friends came to visit and kept in touch and kept me going. The doctors, nurses and auxiliary staff at Ratchaburi Hospital were really excellent, too. I don't think they have had much experience of caring for Westerners but if I was to get sick again I would have little hesitation in being admitted there.

I had some moments of despair too and at times a real fear of dying, based on nothing other than an awareness of the seriousness of the infection and the possibility of it suddenly erupting or re-erupting. I have lived in constant fear of fever and high body temperature over these last few months; both indicators of bacterial infection. Also concerns about the continued effectiveness of antibiotics in the event of re-infection due to the amount of the stuff that has already been pumped into me over the last few months. I have faith in God, I would like to tell you it was unshakeable, but I need to say I had moments of doubt, when fear gripped me and I didn't like being in thrall to it one bit.

Nurses were responsible for two of my setbacks by quite literally attacking my wound. One, as mentioned above, scraped the wound with a piece of metal and another took to cutting away the dead tissue from around the wound and in so doing cut into a live part of the wound. I am not going to be over critical - they were doing what they normally do and probably had no idea of my background.

There were moments when I felt the best thing to do would be to get on a plane and get back to the UK as quickly as possible. However in the cold light of day I would have to say my treatment overall was good and most importantly I am alive, I have all my limbs, I don't have any infection and I should be back to full capacity in the near future. I think I might have benefitted from better advice about managing the wound after discharge from both hospitals.

I also think I probably tried to do too much too soon as I was under the impression that this is what the doctors wanted; I could say this equally of the doctors in both The Philippines and Thailand. This wasn't actually what they wanted but it is what I believed they were advising. I think they could also have given better advice about caring for the wound. I say this because in effect I ended up with a chronic wound. But let me stress, overall, I am not complaining.

Finally it cost a lot of money, in total about £4,000 GBP to date; half of this was covered by my own insurance. Fortunately we had some savings so were able to cover those costs which were not insured: the only problem is I didn't know I wasn't covered and that has caused some rancour and left a bad taste in my mouth. Looking on the bright side, I am on the mend, I have managed to get my BP and heart rate under control again, and I am feeling a lot brighter and more optimistic.

There is no moral to this story. I think I was just unlucky. I don't think I was irresponsible or significantly contributed to what happened. I don't doubt that I will go galloping to an emergency room if I sustain cut(s) again, no matter how slight. But an experience and I am glad to be on the road to recovery.