*Nosocomial, meaning "(of a disease) originating in a hospital."
Even the luckiest, most heedless, most bulletproof product of the '60s runs headlong, one day, into the fact of his own mortality.
Or in Mr. Emmet's case, an inadequately propped-open double hung window from our not-quite Craftsman bungalow whose cord had rotted out ran headlong into his left hand ring finger while he was painting it. The window, I mean, not his finger. Here it is, Satan's aperture:
You can see where his finger was, right in the middle, and no, that's not marijuana below the window.
On December 10, three days after the day that lives in infamy, the window does its guillotine impression and I drive Mr. Emmet to the local, well-regarded, hospital. They hook him up to an antibiotic drip and put a football sized bandage on the affected finger. The X-ray reveals that the bone in the tip of his finger is snapped, luckily without involving the joint. They send for the on-call plastic surgeon, because the (contracted) ER doc doesn't do hands; only the plastic surgeon does hands.
The plastic surgeon is busy with butt lifts and rolls in 30 hours later. Meanwhile, Mr. Emmet remains hooked up to the antibiotic drip and entertains the staff with his impression of Matthew McConaughey at the end of True Detective.
After the surgery and some further shenanigans (lost chart, wandering attending doc), Mr. Emmet is finally released 48 hours after he arrived (I wonder if his Medicare and good supplemental insurance play a role in the lack of urgency about discharging him). He takes another antibiotic as prescribed by the surgeon for ten more days.
In January, Mr. Emmet has minor surgery at the plastic surgeon's office to remove the pin from his finger. Doc prescribes 10 days of Cipro. Seems like a lot to me, but Mr. Emmet doesn't want gangrene and takes it.
At the end of January, after his first week off antibiotics since early December, Mr. Emmet gets very sick in the gastrointestines, including nasty and alarming symptoms. Hermione-like, I go to the library, or as it's known in the Muggle world, the Google.
Clostridium difficile is the most common of the three common hospital-related infections (the other two are MRSA and CRE. C. difficile
is present in the gut (intestinal tract) of approximately 3% of all adults and 66% of children. Healthy people are not usually affected by C. diff. However, some antibiotics may alter the balance of good bacteria in the gut, allowing C. diff to multiply and cause diarrhea, and possibly more serious illness.
The reason most cases of C. diff infection occur in healthcare environments is because of their link to antibiotic therapy - a significant number of hospitalized patients are on antibiotics. In industrialized countries approximately four-fifths of all C. diff cases occur in patients aged over 65 years.
The CDC
estimates that there are half a million cases of hospital-related c. diff. in the US every year, with about 29,000 deaths. Its incidence
nearly doubled between 2001 and 2010. As it multiplies in the gut, c. difficile releases toxins that attack the lining of the colon and can even result in it being perforated. With a lot of vulnerable hosts (all the people on antibiotics), the infection spreads through hospitals unless there's a lot of handwashing and bleach -- alcohol doesn't kill c. diff. Furthermore, c. diff. is becoming not only more prevalent but harder to get rid of as it builds resistance to the specifically targeted antibiotics that used to kill it. The infection
recurs about 25% of the time. As a last ditch treatment, after multiple recurrences, doctors have been using
fecal transplants.
On February 2, Mr. Emmet admits under rigorous cross examination that his symptoms are worse than he'd acknowledged. I drag him to our doctor, who agrees with the Google diagnosis. "What else could it be?" (subsequent tests eventually confirm it). He prescribes Flagyl. I purse my lips a bit, recent studies having suggested that as c. diff. has become more antibiotic-resistant, the standard treatment of Flagyl has become less effective. But IANAD. Mr. Emmet takes the 10 days of Flagyl.
Four days after the last Flagyl, Mr. Emmet's symptoms return, at first tentatively. Then the c. diffs roar back and they're really mad.
Our doc (also really mad because he hates when his treatments don't work) prescribes 10 days of vancocymin. I purse my lips some more (dose is low, and it should be more than ten days, what about fidaxomicin, a new antibiotic that looks to be better at preventing recurrence) but he also refers Mr. E. to a gastroenterologist and makes a call to get him in right away. Kerfuffle ensues when drugstore doesn't have any vancomycin in stock and it's not in formulary for Medicare or supplemental or both. I check and point out that fidaxomicin IS in formulary, but Doc, even furiouser because he hates insurance companies, makes calls; exception granted for vancomycin.
Mr. Emmet starts vancomycin, but it doesn't work for four very scary days and symptoms continue, including the ones that suggest that the lining of the colon is eroded or whatever the right term is.
The gastroenterologist, who appears to be 18 but is very engaging and bright, increases vancomycin to 14 days. Like our regular doc he recommends probiotics. By this point Mr. Emmet is taking two probiotics (including s. boulardii, technically a yeast and not a probiotic) and psyllium husk, eating bananas and live culture yogurt and eschewing alcohol and red meat (but still drinking coffee because of its life-giving properties). I ask what about pulsing (ending the course with doses given a few days apart), given that the bacterium is increasingly antibiotic-resistant and pulsing is shown to be more effective in preventing recurrence. But IANAD and he gives me some vague non-answer.
Our doc and the specialist both react negatively to the idea that we should tell the hospital about the c. diff., but Mr. Emmet calls them anyway, and gets back a bland but cordial nonresponse. Hospitals in California and 26 other states have some reporting requirements w/r/t hospital acquired infections (HAI), but there are vast loopholes. In California, the hospital is required to report only HAIs that are diagnosed while the patient is in the hospital. So Mr. Emmet's doesn't count as hospital acquired for purposes of California's record keeping. Some studies might characterize it as community acquired, while others would not.
The CDC has repeatedly warned hospitals and health care providers about the overuse of antibiotics. Word of this does not seem to have reached our local hospital. What's more striking to me about Mr. Emmet's experience is the sense that the patient and his family are on their own. No one in the hospital was apparently responsible for noticing that Mr. Emmet waited 30 hours for a procedure that took 25 minutes, or that he waited six hours the next day to be discharged after he was cleared to go. The nurses were afraid to contact the surgeon, who had forgotten to relay his discharge orders to them, and didn't have the cellphone number of the attending doc, who wandered off with Mr. Emmet's chart; we tracked them both down ourselves. The surgeon didn't seem to feel any responsibility for (or even know about?) all the antibiotics he was given during the 30 hours, and the gastroeneterologist later tut-tutted over the huge dose of Cipro the surgeon prescribed. But I am sure that neither the hospital nor the surgeon will review the case to figure out whether it could have been handled differently -- and certainly not together.
Mr. Emmet has been off the vancomycin for a week; the jury of gut health is still out. I ask him if he has experienced his brush with c. diff. as an intimation of mortality. Absolutely not, he says. He still expects to be lifted bodily into heaven when his time comes. And there he will find that Jesus runs a beer joint.
P.S. Looks like it's back...
UPDATE: Many, many thanks for the good wishes and the excellent suggestions. We're taking notes and following up!