Necrotizing Fasciitis Missed in an Oregon Emergency Room

Necrotizing fasciitis is a bacterial infection that destroys soft tissue. In an emergency department it can present the way an ordinary skin infection presents: a red, swollen, painful patch of skin. What separates the two is not how the skin looks on arrival. It is what has to happen next, and how quickly.

A surgical disease, not a skin disease

The CDC describes necrotizing fasciitis as "a rare, but serious bacterial infection" that "can develop very quickly into a life-threatening emergency", and says people who have it "need immediate hospital care, antibiotics, and surgery."¹

Surgery is on that list for a mechanical reason. Antibiotics travel in blood. The CDC explains that antibiotics sometimes cannot reach all the infected areas "because the bacteria have killed too much tissue and reduced blood flow", and that when this happens "healthcare providers must surgically remove the dead tissue."¹ That operation is debridement: cutting away dead and infected tissue until healthy tissue is reached.

A 2025 surgical review in Updates in Surgery states the point directly. Source control through early and aggressive surgical debridement is the most important determinant of outcome in these infections, and broad-spectrum antibiotics, while essential early in the treatment course, do not substitute for surgical management.²

The treatment is not a prescription. It is an operation, and the interval before it is measured in hours.

Why the first impression is cellulitis

Cellulitis is a non-necrotizing skin infection treated with antibiotics. Early necrotizing fasciitis can look like it. The CDC puts it plainly: there are "many infections that look similar to necrotizing fasciitis in the early stages", which the agency says can make diagnosis difficult.¹

The Updates in Surgery review reports the scale of that problem. A systematic review of 1,463 patients found these infections were misdiagnosed at first presentation in 71 percent of cases, which the authors connect to delays in diagnosis, in antibiotic treatment and in referral for surgery.²

The same review collects how the infection presents across the published literature: swelling in 81 percent of cases, pain or tenderness in 79 percent, redness in 71 percent, warmth in 44 percent, blisters in 26 percent, skin necrosis in 24 percent and crepitus — a crackling of gas under the skin — in 20 percent, with fever in 40 percent and low blood pressure in 21 percent.² In that collection, the findings most particular to a necrotizing infection were recorded in a smaller share of cases than the findings it shares with cellulitis.

The findings that point past cellulitis

A 2024 review in the Canadian Medical Association Journal, written for emergency clinicians, states that pain out of proportion to findings on physical examination should raise suspicion of a necrotizing soft-tissue infection.³ The CDC lists among the early symptoms "Severe pain, including beyond the area that's red, warm, or swollen".¹

The CMAJ review adds that crepitus and blisters are infrequent, late signs, and that the absence of skin findings does not exclude the diagnosis; progression of the redness, and signs of shock such as low blood pressure and altered mental status, increase the likelihood.³ Once the infection is suspected, that review describes urgent consultation with a surgeon, chosen by the site of the infection, as critical, and states that most cases require wide, serial debridement — three to four operations — for source control.³

Why the tests do not settle it

Waiting for a test to decide the question is itself a decision. The Updates in Surgery review reports that there are currently no laboratory or radiological findings that provide a definitive diagnosis, and that while scoring systems and typical clinical signs can strongly suggest it, the only way to confirm the diagnosis is through surgical intervention.² The Laboratory Risk Indicator for Necrotizing Fasciitis score is described there as having a sensitivity ranging from 36 to 77 percent, which the review calls a sub-optimal screening tool, insufficient for confidently identifying early cases.²

Imaging carries the same limitation with an added cost. The review notes that because imaging may delay necessary surgical intervention, current guidelines give no definitive recommendation for its use, that CT should be used only when immediate surgical exploration is not required, and that MRI is not recommended where suspicion is high.² The CMAJ review states that in patients with clinical signs of the infection, imaging adds little value and is associated with delays in diagnosis and management, and that laboratory findings can support but not rule out the diagnosis.³

Time to debridement

The timing question has been measured. A 2020 systematic review and meta-analysis in the World Journal of Emergency Surgery pooled 109 studies covering 6,051 patients with necrotizing soft-tissue infections, of whom 1,277 died, and carried 33 of those studies, covering 2,123 patients, into a quantitative analysis.⁴

Across the ten studies reporting a six-hour cut-off, mortality was lower when surgery followed within six hours of presentation than when it was delayed beyond six hours: 19 percent against 32 percent, with an odds ratio of 0.43 (95% CI 0.26–0.70).⁴ Across the sixteen studies reporting a twelve-hour cut-off, surgery within twelve hours was again associated with lower mortality, 19 percent against 34 percent.⁴ At a twenty-four-hour cut-off the difference was not statistically significant.⁴

Two findings in that analysis bear on the hospital-side interval. First, the interval that moved the result was measured from presentation at the hospital to surgery — which the authors describe as encompassing both doctor delay and part of the system delay. Delay measured from the onset of the patient's symptoms to presentation, or to surgery, did not significantly affect mortality in that study.⁴ Second, the authors report that none of the time-related variables they assessed significantly reduced the amputation rate, and point instead to factors such as comorbidities, the local state of the tissue and the severity of disease.⁴

Professional societies have published their own intervals. The Updates in Surgery review records that the Eastern Association for the Surgery of Trauma guidelines advocate debridement within twelve hours of suspected diagnosis, and that joint guidelines of the World Society of Emergency Surgery and allied bodies advocate intervention within six hours of admission.²

What Oregon law states about the duty

Oregon states the physician's duty by statute. Under ORS 677.095(1), a physician licensed to practice medicine or podiatry by the Oregon Medical Board "has the duty to use that degree of care, skill and diligence that is used by ordinarily careful physicians in the same or similar circumstances in the community of the physician or a similar community."⁵ Subsection (2) states the same duty for a physician associate licensed to practice medicine by the board.⁵

The six-hour and twelve-hour intervals above are recommendations published by medical societies, and the percentages are findings from medical research. They are set out here as what that literature says. The statutory duty quoted above is a separate question, and this post does not connect the two.

Oregon's wrongful-death statute makes causation part of the condition for an action. It opens: "When the death of a person is caused by the wrongful act or omission of another …"⁶ Where the alleged fault is an interval rather than a single act, that is the question the evidence has to reach.

Oregon's time limits

A claim for injuries arising from medical care runs under ORS 12.110(4), which requires an action "to recover damages for injuries to the person arising from any medical, surgical or dental treatment, omission or operation" to be "commenced within two years from the date when the injury is first discovered or in the exercise of reasonable care should have been discovered."⁷ The word "injury" there is a term of art. In Gaston v. Parsons, 318 Or 247, 864 P2d 1319 (1994), the Oregon Supreme Court held that the word, as used in ORS 12.110(4), "consists of three elements: (1) harm; (2) causation; and (3) tortious conduct." The same opinion holds that the period "begins to run when the plaintiff knows or in the exercise of reasonable care should have known facts which would make a reasonable person aware of a substantial possibility that each of the three elements (harm, causation, and tortious conduct) exists."⁸ The subsection also sets an outer limit, requiring that "every such action shall be commenced within five years from the date of the treatment, omission or operation upon which the action is based", with the statute's own exception where no action was commenced within five years because of fraud, deceit or misleading representation.⁷

Where the infection causes a death, ORS 30.020(1) governs. Under that subsection, "The action shall be commenced within three years after the injury causing the death of the decedent is discovered or reasonably should have been discovered by the decedent, by the personal representative or by a person for whose benefit the action may be brought under this section if that person is not the wrongdoer."⁶ It then provides: "In no case may an action be commenced later than the earliest of: (a) Three years after the death of the decedent; or (b) The longest of any other period for commencing an action under a statute of ultimate repose that applies to the act or omission causing the injury, including but not limited to the statutes of ultimate repose provided for in ORS 12.110 (4), 12.115, 12.135, 12.137 and 30.905."⁶ Three years after the death is an outer bar rather than a starting point, and it is not always the operative one.

This article is educational

This article describes Oregon law in general terms. It is not legal advice and does not create an attorney-client relationship.

Time limits matter. Most Oregon personal-injury and auto-accident claims must be filed within two years of the injury or accident. Medical malpractice claims must be filed within two years of when you knew or reasonably should have known of the negligence, with an outer limit of five years from the act itself (with a fraud exception). Wrongful death claims must be filed within three years of the date of death. Claims against public bodies (cities, counties, state agencies, public hospitals) require a notice of claim within 180 days. Missing these deadlines typically ends a case.

If you think you may have a claim, call Huegli Law at 971-317-6436 for a free case review. Todd Huegli is licensed in Oregon and consults on cases in Oregon only.

Footnotes

1. About Necrotizing Fasciitis — Group A Strep, Centers for Disease Control and Prevention. https://www.cdc.gov/group-a-strep/about/necrotizing-fasciitis.html ↩ ↩² ↩³ ↩⁴

2. Necrotizing soft tissue infections: a surgical narrative review. Updates in Surgery (2025). https://link.springer.com/article/10.1007/s13304-025-02222-0 ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶ ↩⁷

3. Necrotizing soft-tissue infections caused by invasive group A Streptococcus. CMAJ 2024;196(38):E1291. https://pmc.ncbi.nlm.nih.gov/articles/PMC11573382/ ↩ ↩² ↩³ ↩⁴

4. Time is of the essence when treating necrotizing soft tissue infections: a systematic review and meta-analysis. World Journal of Emergency Surgery (2020). https://wjes.biomedcentral.com/articles/10.1186/s13017-019-0286-6 ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶

5. ORS 677.095 — Degree of care and skill required. https://www.oregonlegislature.gov/bills_laws/ors/ors677.html ↩ ↩²

6. ORS 30.020 — Action for wrongful death; when commenced. https://www.oregonlegislature.gov/bills_laws/ors/ors030.html ↩ ↩² ↩³

7. ORS 12.110 — Action for professional malpractice. https://www.oregonlegislature.gov/bills_laws/ors/ors012.html ↩ ↩²

8. Gaston v. Parsons, 318 Or 247, 864 P2d 1319 (1994). https://static.case.law/or/318/cases/0247-01.json ↩