She had just given birth and was full of joy. Then a deadly bacteria began ravaging her body, triggering a frantic race to keep her alive. But at what cost?
IT'S STILL DARK OUTSIDE as Monica Sprague and her fiance, Tony Jorge, drag themselves out of bed. It's a muggy morning in August 2007. Their first-floor apartment in the yellow two-family with low ceilings and plush beige carpeting is quiet - Monica's 9-year-old daughter from her first marriage is staying overnight with Tony's mother. Monica and Tony are out the door by 5:30, driving down their narrow one-way street in Ayer, a rural town 35 miles northwest of Boston.
The journey for both of them to get to this day has been a bumpy one. Previous marriages failed. Families splintered. Cancer took all but one of their parents. Tony, short and stocky with a handsome, boyish face, jet-black hair, soothing voice, and a Bluetooth headset perpetually stuck in his ear, was born in Portugal, came to the States with his parents when he was 5, and grew up in Hudson. Monica, with shoulder-length brown hair and a bright, toothy smile that could light up a small town, was raised 10 miles away in Ashland, the youngest of six kids. Staying close to home, they got to know some of the same people, and first crossed each other's paths at a Fourth of July party. Now, a little more than three years later, they are walking together through the front glass doors of Emerson Hospital in Concord to begin their next chapter together.
She's 35. He's 40. They're not expecting any complications for her scheduled C-section, but Monica did have gestational diabetes during her first pregnancy and again for this one. That's why, as a precaution, they had talked about what they should do if something went wrong.
"Save the baby," Monica said.
"We can make another baby," Tony answered. "We can't make another you."
Just after 6 a.m. on Thursday, August 9, Monica is admitted. She slips into her gown while Tony gets into scrubs. This will be her second delivery, but his first, and he doesn't want to miss a thing. He's so nervous that after getting himself changed and sterile, he steps outside for a cigarette, a sin that gets him yelled at by a nurse, who orders him into new scrubs and to wash up again.
By the time he's ready, the doctors have started. They call him into the operating room, and he goes straight to the head of the bed. From behind his blue surgical mask, he sneaks a peek around the curtain just in time to watch his daughter be pulled out and unleash her first cry. The doctor hands the baby to a nurse, who gives her to a beaming Tony, who gives her to Monica, a final handoff that a nurse captures on Tony's digital camera. Brown-haired, blue-eyed, 6-pound-14-ounce Sofia Maria is then taken for a few routine tests while surgeons stitch up Monica's abdomen and Tony leaves to pick up Monica's older daughter, Madalyn, and bring her back to the hospital. By noon, the whole family is together for the first time.
When Monica gets a fever later in the day, she passes it off as hormones, and nobody's alarmed, least of all Tony, who goes home to rest. But the next two days her fever lingers, and she's not having a bowel movement. Prune juice, suppositories, teas, nothing works. On Sunday morning, Emerson doctors, still puzzled, move her into the intensive care unit. She's feeling bloated and experiencing sharp jabs in her abdomen, almost as if she's giving birth again. She's also wearing a mask to avoid passing on whatever she might have to her baby. With her pain still not subsiding, Monica finally calls Tony at home, crying in agony. He rushes to the hospital.
As soon as he arrives, doctors tell him they need to get her to Boston. They've run some cultures that show she has a strain of streptococcus, and while they don't know how bad it is, it's obvious she's deteriorating rapidly. They have already called Massachusetts General Hospital and reached the senior surgical resident, Claudius Conrad. They mentioned the positive strep test and that she's unstable; they're fairly certain about what's wrong with Monica and just want to get her emergency care immediately. The Emerson doctors ask him if they should put her in a helicopter for a five-minute ride or an ambulance for a 45-minute drive. Conrad doesn't hesitate. He senses that the window of time to save her is closing. Fast.
Just before noon, Monica is rushed into the helicopter while Tony jumps into his car and races down Route 2 to Interstate 95 at close to 90 miles per hour. Getting on the Mass. Pike, he pays the toll with quarters, but when he comes to the Allston-Brighton exit, he just throws whatever change he has at the booth operator. "I have to get to the hospital!" he yells before speeding off.
He's still driving when the MedFlight copter lands on the MGH helipad. It's 12:12 p.m. when Monica is wheeled into the emergency room, where she's pounced on by a team of residents, who poke and prod her body, searching for the source of her pain. They insert a catheter to pump some fluids into her, and they notice that her belly is as hard as a board, a strong sign of inflammation or infection. The on-call surgeon in the operating room hustles down and finds Monica hysterical and struggling to breathe. Her heart is racing at 160 beats per minute and her blood pressure is dangerously low at 70/30 - and dropping.
Tony arrives just before 1 p.m. and finds Conrad, who, in polite yet blunt language, tells him that Monica is in bad shape, that her body is going into septic shock, and that she has some kind of an infection and has to go to the operating room immediately.
"She has a high chance of dying," Conrad tells Tony, "but we'll do everything possible."
Tony blurts back the only thing that comes into his head. "We just had a baby. She has a 9-year-old daughter. Do what you can."
Tony goes to see Monica, who knows that she has a severe infection and needs surgery, but nothing more. Just before she's wheeled away, she pleads with Tony to not let doctors remove her uterus or ovaries, in case they want more children. But by now, she's fading, and doctors are racing. It's 2:30 p.m. Monica disappears into the operating room, where she's slipping into unconsciousness. A breathing tube is inserted into her mouth, and her eyes slowly close.
Back in the emergency room, Tony is left standing there, alone. Three days after celebrating the happiest moment of his life, the birth of his first child, now he can only wonder if he'll be raising her by himself.
IT WAS CLOSE TO 90 DEGREES on the Fourth of July back in 2004, making the home on the border of Worcester and Shrewsbury overlooking Lake Quinsigamond the perfect setting for a summer bash. Everyone was eager to jump on the new water trampoline or take the jet ski out for a spin on the 4-mile-long lake. The grill was smoking, and burgers, dogs, steak tips, macaroni salad, and marinated chicken wings filled the plates of the 30 friends and relatives who filled the backyard.
Toting a cooler filled with cupcakes and cookies, Monica came with her daughter Madalyn and roommate Denise Hunt. It wasn't an easy time for Monica. She was going through her divorce. A working mom, she worried that single men might judge her for having a broken 10-year marriage and a young daughter. But the cookout was being thrown by the parents of her childhood best friend, Susan O'Connell. There was no way Monica would miss it.
Susan and Monica grew up together in Ashland, and both married young. But while Susan's marriage flourished, Monica's foundered. Susan wanted to see Monica happy again, and when she remembered that her own husband, Ken, had a buddy who was also in the midst of a divorce, she couldn't help herself. She notched an arrow for her bow and invited Ken's friend and her friend to her mother's cookout.
"I didn't want to fix them up and be responsible if it didn't work out," Susan says now. But in her heart, she thought they might connect. "Tony's a very giving person, never selfish. If you were cold and even though he didn't know you well, he'd take his own shirt off for you. Monica is the same way. Very big heart. If you needed her, she'd do anything. I just thought their personalities might click." Plus, she knew that if anyone was in no place to judge Monica, it was Tony, who before turning 40 was going through his second divorce. "They both had a hard time with marriage," Susan says, "but they both wanted a family and liked being married."
Monica and Tony did talk that day, but the timing wasn't great, with both their divorces dragging out. A few months passed before they joined Ken and Susan for dinner at an Irish pub in Worcester, and shortly after that they had their first date at Vinny T's, followed by the dark sci-fi thriller Constantine. But things didn't really bloom until one night in January 2005, when Susan and Ken invited them both to their house in Grafton. Monica brought Madalyn to play with Susan's four kids, and when a snowstorm blew in and stranded them, Monica and Tony stayed up all night.
Monica, in only her few short meetings with Tony, had begun to see things in him that surprised her, like the warmth he showed around Madalyn, always asking if she minded him spending time with her mom. And so that night Monica opened up, telling Tony about her joys and struggles, from growing up with a sister and four brothers, to typical sibling fights, to her parents' deaths (her mom, a certified nursing assistant, died of uterine cancer; her dad, a nuclear physicist, also died of cancer), to her job in the sales audit department at TJX in Framingham. She talked about getting married at 21 and why it fizzled a decade later after they'd moved to Florida, but how the best thing to come out of it was Madalyn, who was born five years into the marriage.
Tony shared, too. He told Monica about his father, who worked for
They kissed that night for the first time. Over the next two years, they went to movies and carnivals and flea markets, and Monica grew more enamored each week, watching Tony bond with her daughter. "I love kids," Tony recalls of those early months dating. "Madalyn was all good with it. She was happy for us, but especially for her mother." As for Monica, Tony says that something felt different from his previous relationships. "We were very natural together, never had any major arguments. We're like a puzzle. We just completely fill each other in; there are no missing pieces."
In December 2006, a few months after they'd moved in together and a few days after Tony's 40th birthday party, Monica gave him a belated present. She told him she was pregnant. Two weeks later, on Christmas Day, at their apartment in Ayer, Tony got down on one knee and proposed with a beautiful ornate Irish claddagh ring.
IMAGINE A FAST-MOVING FOREST FIRE. It's burning and hissing through the woods with devastating results, leaving in its wake charred leaves and twigs and grass. The only way to contain it is to anticipate where it's going and not worry about where it is or where it's been. That damage is done. Can't be saved. But get ahead of it and work backward, directly toward it with sand and water, and maybe, just maybe, you'll minimize the wreckage.
It's almost 3 p.m. on the afternoon of Sunday, August 12, and Marc de Moya, a 36-year-old trauma surgeon with the youthful features of a teenager, is about to assume the role of firefighter on the body of Monica Sprague, a woman who just gave birth three days ago.
He suspects he knows what's eating her up inside. The doctors at Emerson Hospital had tentatively diagnosed it when they called MGH that morning. But he doesn't know for certain if they're right, that inside of her a bacteria is raging, destroying her organs and tissue at a ridiculously fast pace, moving up her abdomen wall 3, 4, 5, 6 inches in a single hour. He won't know just how sick she is until he opens her up. But her symptoms tell him it's bad and that she might be dead by sundown if he doesn't move quickly.
To understand what was killing Monica on this summer Sunday afternoon, you have to go back and read up on 18th-century battle wounds. That's when British naval surgeons and French military hospitals first began seeing this grim disease in soldiers and seamen. It turned the victims' skin black; the doctors called it hospital gangrene. A century later, in 1871, a Confederate Army surgeon named Joseph Jones wrote about spotting a similar soft-tissue infection during the Civil War: "I have seen the skin in the affected spot melt away in 24 hours . . . whilst a deep blue and purple, almost black, areola surrounding the dead mass spreads rapidly in ever increasing circles. This is witnessed most generally in the worst and fatal cases." It wasn't until 1952 that a doctor would attach a more scientific name to this ugly disease. Bob Wilson put together the signs and symptoms of something that up until then had been called everything from a "killer bug" to "galloping gangrene" and proposed the term "necrotizing fasciitis." Necrosis is the death of cells or tissues through disease or trauma; fascia refers to the thick covering of the muscles, like the glue and nails that bind a floor to a foundation. Today, however, you know it as something that sounds like a line from a cheesy late-night Cinemax horror flick - "flesh-eating bacteria."
In a world of bad bugs, there aren't many scarier than soft-tissue infections, which can range from a mild redness on a fingertip to a deeper infection of muscle to something that penetrates into the cavity and spreads like wildfire. What makes necrotizing fasciitis [pronounced NECK-RO-TIE-ZING FASH-EE-EYE-TIS] such a terrifying streptococcal infection is the sheer randomness of it, the speed at which it moves, and its deceptive signs: The classic black lesions on the skin appear after the infection has moved disastrously through deeper tissue. Some people get it vaginally or anally. Others might get it through a tiny wound that lets the bacteria seep in. Most people suffer nothing more than a minor skin irritation, if they get anything at all. Others might suffer scarring or lose a fingertip or even part of a limb. But the worst cases? Well, those are straight out of Stephen King's twisted mind. And in those cases, death usually comes swiftly, and mortality rates can range as high as 80 percent.
Nick Daneman, an infectious disease consultant at Sunnybrook Health Sciences Centre in Toronto, studied all the literature on outbreaks of the bacteria from 1965 to 2004. He found outbreaks that involved as many as 56 patients, lasting from one day to three years. Most people became infected after a surgery or delivery. The most common ways people got it were from another patient or from a healthcare worker who was unknowingly infected. Adding to the mystery is how the infection takes hold differently in different people. "There's a lot to be learned," Daneman says, "about why some people will get simple strep throat and others severe fasciitis."
A physician with the Centers for Disease Control and Prevention in Atlanta says that may remain one of medicine's great mysteries. "There will always be healthy people who out of the blue have a horrible, heart-wrenching, and devastating infection," says Chris Van Beneden, a medical epidemiologist with the CDC. "The same strain that may cause nothing in you may cause a mild infection in me and devastating illness in someone else."
Not exactly a comforting thought. In a study Daneman published in the Annals of Internal Medicine last August, he reviewed 2,351 cases of invasive Group A strep from 1992 to 2000, of which 253 resulted in necrotizing fasciitis. He found that just 12 percent of all the patients caught their disease in a hospital - most picked it up in the community. Of the 291 who acquired it in a hospital, 10 percent were part of an outbreak and 90 percent were isolated cases.
"Once you have necrotizing fasciitis," says Stephen Zinner, an infectious disease specialist at Mount Auburn Hospital in Cambridge, "the treatment really is heroic type of surgery." He describes the disease as a "chance event," and he says doctors seeing it for the first time might even be puzzled initially. "It's a subtle diagnosis," says Zinner, who was not involved in Monica's case, "not initially so clear that every doctor would say, 'Ah, that's what it is.'"
If anything, the questions surrounding necrotizing fasciitis have only reminded all of us that the world of medicine is a scary place that's full of cruel irony. Our skin, for example, is our greatest defense against infection. But oftentimes, we must open up the skin - with an intravenous line, catheter, or scalpel. It's that opening that weakens our immune system and provides a portal for a bacterial strain to get into the body and do its worst damage. Similarly, we think of hospitals - with their white walls and their doctors in white coats with their stainless-steel tools that have all been sterilized - as germ-free places. The truth is that hospitals are places for sick people, and for doctors and nurses who are treating sick people, all of whom breathe germs into the air and infect water fountains, doorknobs, elevator buttons, beds, and anything else they put their hands on. We go to hospitals to get healthy, but sometimes, despite the hospital's best efforts, we also get sick there.
How the bacteria that caused necrotizing fasciitis got into Monica's body is a tangle still being unraveled. But three possibilities emerged in the days that would follow: She caught it from a healthcare worker at Emerson Hospital; she caught it from another patient at the hospital; or, perhaps scariest of all, she was carrying the bug, totally unaware, when she walked in the door that morning.
IT'S NOW A LITTLE MORE THAN 72 HOURS after Sofia was born. A sedative has knocked Monica out. A breathing tube is in. A cocktail of drugs has paralyzed her body. As de Moya examines her in an MGH operating room, her low blood pressure isn't worrying him so much as the milky pus leaking out of her abdominal incision. His mind races to her C-section, and he wonders if maybe her injury is to her bowel or uterus.
Doctor and patient on this day aren't that far apart in many ways. This isn't a teenage gunshot victim or an elderly man suffering a heart attack. For de Moya, the son of a Cuban immigrant father and Polish-American mother whose wire-rimmed glasses, narrow face, and slight build belie the assertive way with which he carries himself, it's impossible to look at Monica and not see a little of his own life. She's a happily engaged 35-year-old mother of two. He's a happily married 36-year-old father of two.
Three days earlier, when Monica's abdomen was cut open, it was to welcome a new life. Now, as de Moya opens her up again, it is to save her own life.
Immediately he is struck by how much pus there is and how it has extended all the way above her navel. He also notices that the fascia - the head-to-toe web of soft tissue that penetrates and surrounds muscles, bones, and organs, which should provide some resistance as he slides his hand over it - is gone. It's as if acid has been poured over the underside of her skin and dissolved the connective tissues. Now de Moya knows what he's facing. He's seen soft-tissue infections, including plenty of cases of necrotizing fasciitis, but never something this severe.
After exploring Monica's bowel and finding no injury there, de Moya turns his attention to her uterus, wondering if that's where the infection began. Had Monica been a 60-year-old woman, he would not blink at removing it, to be safe. But she's 35. She just had a baby. She has a 9-year-old daughter. Her fiance is standing outside. Maybe they want more kids. It's the sort of decision every doctor hates to make under pressure, and de Moya wishes he could take his time. But every second he wastes is another second this bug climbs up her body, toward her chest cavity. The gynecologist with him, Marcela del Carmen, takes a look, and together they decide her uterus looks healthy enough. They hold off, for now, on a hysterectomy.
But that's the only decision that can wait. De Moya needs to get ahead of this infection. If he's not aggressive, she'll die. It's that simple. It's not the time to worry about neatness or cosmetics or scars. Right now, the only way he can slow it down is with antibiotics, fluids, and debridement, a tedious process by which surgeons remove dead, damaged, or infected tissue. After two hours of removing tissue, de Moya is satisfied he has at least slowed things down and that Monica is stabilized; he has her moved up to a corner room in the intensive care unit. Typically in the ICU, each room has one patient and one nurse. Sometimes nurses get two patients at a time. Monica is in such tough shape that she is assigned two nurses all to herself.
As afternoon turns to evening, de Moya finds Tony in the waiting room.
"There's a strong chance she could die," he tells Tony. "She might get sicker and could die this evening. It's very touch-and-go."
Gradually, friends and family descend on the hospital to surround Tony. He calls Ken and Susan, who are keeping Madalyn distracted by letting her play at their house with their kids. After Monica's ex-husband retrieves Madalyn, Susan heads down after midnight while Ken stays with their kids.
Rae Allain, an ICU surgeon, takes over from de Moya. She, too, looks at Monica with a special urgency and sympathy. Allain has a daughter the same age as Madalyn. By now, everybody is certain it's necrotizing fasciitis. But even though Monica is stabilized, she's suffered massive damage to her abdominal wall and lower organs.
When Allain checks in on her a few hours later, she's told Monica is deteriorating rather than improving. She suggests starting a drip of epinephrine - basically adrenaline - to give her heart and blood pressure a boost. It's risky, because it also can cause the heart rate to rise and is usually a last-resort drug. The nurses are reluctant, but Allain sees little choice. The drip is just being set up, though, and Monica's head is being placed back down on her pillow, when her heart stops. Her pulse vanishes. Flat line.
The operating room when a patient goes into cardiac arrest is one of the few things TV medical dramas get right. It's like watching a well-oiled kitchen in a first-class steakhouse on a Saturday night. Everybody knows where to go and what to do. And so with Monica's life slipping away, Ricardo Verdiner, a beefy clinical fellow, is there to pump her chest. As routine as bringing a person back from the clinically dead is, it's no small feat. It has to happen fast; brain damage can begin in less than five minutes.
Back in the waiting room, Tony is physically exhausted and emotionally spent. His mind races from his fiancee on the brink of death to their baby girl lying in a hospital 30 miles away, and finally to his stepdaughter, oblivious about how close she is to losing her mother. When it's suggested that he might want to consider having a priest ready to deliver last rites, Tony shakes his head.
"No," he says. She's going to pull through. She has too much to live for.
And he's right. The surgical team gets Monica's heart pumping again quickly and starts the epinephrine drip. As the hours pass and night turns into day, the doctors and nurses monitoring her are able to shift their focus. The question is no longer whether she'll live. The questions now are just how much damage the bacteria did before they were able to stop it, and whether the woman who gave birth only a few days ago will be the same woman who emerges from this coma.
"MONICA, BLINK TWICE if you recognize me."
She's awake, but fading in and out of consciousness as her medications begin to wear off and her head slowly clears. There, standing over her in the ICU of Mass. General, is a familiar, handsome, cleanshaven face and full head of neatly combed dark hair. Tony says it again: "Monica, blink twice if you know who I am." And she blinks. Twice.
It's been almost three weeks since the three-day stretch when Monica delivered her baby by C-section at Emerson Hospital, felt sharp pains in her abdomen, and was rushed to MGH, where doctors pumped her full of antibiotics and scraped away layers of dead tissue inside of her to clean out the flesh-eating bacteria that had almost killed her. Now, with two simple blinks, she answered the one question her fiance, her 9-year-old daughter, and her doctors and nurses had. They knew her body had taken an unimaginable beating and that more surgeries lay ahead. But until those blinks, nobody knew if the old Monica would be back.
While she had lain unconscious in bed, however, the disease had ravaged her body. In its fight to ward off the necrotizing fasciitis, her body had done exactly what it was supposed to do - poured all of its energy into preserving her heart and her brain, so that when she came back, she'd have the same smile, same gentleness, same silly humor.
But her uterus and ovaries, her gall bladder, and most of her colon all had to be removed in her first few days at MGH because of the infection. And her limbs suffered worst of all. The hard fight her body had waged had constricted her blood vessels and restricted the blood flow to her extremities. In the days and weeks after she was admitted - de Moya, the trauma surgeon who saved her life in those first 24 hours, would perform 28 of her 35 surgeries during her two months at MGH - her feet and hands began to shrivel and turn black. She looked like a mountain climber rescued after a week without shelter, suffering from severe frostbite. She was alive, but her limbs were dead.
Only when her breathing tube was removed in early September did doctors finally explain just how bad the damage was and how she had been resurrected from the dead. Once she absorbed everything, she told them to do whatever was necessary so she could get back to being a mother to her girls.
"If you're going to amputate," she told de Moya, "amputate so I can get home."
COMING NEXT WEEK: Frustration and elation lie ahead for Monica.
Doug Most is editor of the Globe Magazine. E-mail him at firstname.lastname@example.org.