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Love In a Time of Trauma: One Man’s Struggle to Survive

Sam Paulos peered over the edge of the dock. The water looked deep enough. One of his cousins had just bought a cottage on Lake of the Woods in northwestern Ontario, near Kenora, and this was Paulos’s first visit. His first swim of the trip, too, and maybe the last of the season. It was Labour Day 2011, and Paulos, a 45-year-old account executive in Toronto, would soon be back home, bracing for winter.

Paulos plunged roughly three metres down, then winced. His left foot had hit the lake’s rocky bottom, and a dull ache spread up his leg, the sort of diffuse pain that comes from jumping out of a tree from too high.

When he surfaced, another cousin, who was standing on the dock, appeared concerned. “Sam, I think you’re bleeding,” he said. Paulos swam to shore and they took a look: a jagged Zorro slash, less than five centimetres long, ran between his left arch and heel. The cousin, a dentist, found some bandages and gauze and cleaned and wrapped the wound, but the laceration suggested stitches, so they headed to the hospital 10 minutes away.

A few years earlier, Paulos had been in a nasty car accident, suffering whiplash and bruised ribs. When he was in his 20s, he’d endured third-degree burns on his hand after a cooking incident. The resilient type, Paulos stayed calm, though the pain had worsened. He was concerned, and annoyed, too, but he wasn’t about to panic.

The triage nurse handed him a form, changed his bandage and told him he would have to wait to see a doctor. Paulos took a seat near a guy with afishing hook through his thumb and passed the time text­ing his new girlfriend, Gayle , a 41-year-old sales and marketing consultant.

Paulos and Kosokowsky had been introduced six months earlier by a mutual friend. The attraction was instantaneous. Paulos thought Kosokowsky’s freckles and double-dimpled cheeks were adorable, and he loved how she was always smiling. Kosokowsky later gushed to her friends about the tall, handsome guy who was “just really, really nice.” The next day, they went on a date. Soon, they were a couple.

Kosokowsky was just heading out when Paulos texted: Cut foot. Going to hospital. She could sense irritation in his brevity. He was visiting his family for only three days and wouldnt want to spend any length of it in a waiting room. But Kosokowsky didn’t take the news too seriously. Paulos was a kid in many ways-an adventurous, fearless guy who loved riding his motorcycle. A little cut wasn’t cause for alarm. “Aw, really? Little boys in the woods,” she typed back.

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A couple of hours after arriving at the hospital, Paulos still hadn’t seen a doctor. The throbbing in his foot was more agonizing by the minute, to an extent that seemed out of proportion to the injury. Fearing he’d been forgotten, he yelled for assistance.

The doctor gave him six stitches and some painkillers and sent him to get some sleep. When Paulos returned to the hospital for X-rays on the morning of September 4, one day after his ill-fated swim, he felt even worse-he couldn’t put any weight on his leg. The next day, Paulos flew home to Toronto. When he landed, airport staff put him in a wheelchair and took him to Kosokowsky in the arrivals area.

“He looked like an old man,” she said. “He was stooped, and his face was grey and drawn.” They loaded into her car. En route to her loft, Paulos kept nodding off. Kosokowsky was worried. She suggested they go directly to the hospital, but Paulos refused-he had just spent hours in a waiting room. His family doctor was always on schedule, so he decided to make an appointment for the following morning. At her place, Kosokowsky unwrapped Paulos’s leg and was horrified to see a swollen patchwork of purple and white flesh. She texted medically inclined friends for advice-they suggested she raise the foot to reduce the swelling.

In the night, Paulos vomited and hardly slept. By morning, he felt himself on the verge of losing consciousness. He told Kosokowsky, “Take me to the hospital now.” They left for Toronto Western Hospital, where Paulos was attended to just after 10:15 a.m.

Dr. Eyal Golan, a critical care physician, was on duty. Paulos was experiencing septic shock with multi-organ failure: the infection had released toxins into his system, and his body was going into survival mode by sending blood to the vital organs at the expense of everything else. Golan gave Paulos fluids, put him on life-support and started him on antibiotics. Then the doctor got to work on establishing a diagnosis.

After inspecting the leg, he suspected necrotizing fasciitis-flesh-eating disease. In such instances of septic shock, each hour of delay (up to six hours) in getting the appropriate antibiotic treatment increases the chance of death by 7.6 per cent. Golan had no idea how long Paulos had been in septic shock. He needed to work fast but first had to rule out competing theories before cutting away at a young and otherwise healthy man’s leg. It might be extreme cellulitis (a skin infection commonly caused by Streptococcus pyogenes and Staphylococcus aureus) or a heart problem blocking blood flow to the leg. But once Golan noticed crepitus-gas forming under the skin, a telltale indicator of flesh-eating disease-he had his diagnosis.

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Gayle Kosokowsky
Unfortunately, there’s no way to reverse necrotizing fasciitis-the tissue is dead. The first procedure is called debridement, an aggressive cutting away of the dead tissue. The plastic  surgery team sliced open Paulos’s foot, and foul-smelling dishwater-like fluid came seeping out. The spread of necrotizing fasciitis is difficult to track because the rot takes place not on the surface but deep down, in the protective tissue and fat. The surgeons cut into the leg, deeper and deeper, until they saw blood-a sign of healthy tissue. They needed to remove the infected portions but nothing more: if they cut too much, the leg wouldn’t be worth saving. Paulos had arrived at the ER mid-morning; by 7:45 p.m., he’d had the operation.

Dr. Jim Brunton, an infectious diseases specialist, examined blood cultures to determine which bacteria had caused the infection, so he could narrow down the list of antibiotics Golan had administered. Eventually, tests revealed a strong presence of Aeromonas veronii biovar sobria, found in lakes and streams, and Clostridium bifermentans, found in lake sediment, soil and sewage.

Six of Paulos’s closest friends and one cousin huddled together in the waiting room, but despite the company, Kosokowsky felt isolated. She was acquainted with everyone, but not well, and was in shock over the events of the past few days. Later, when she overheard someone refer to her as “the girl,” she nearly burst into tears.

Golan monitored Paulos through the night for significant signs of improvement. None came. In the mor­ning, four days after the swim, he still required the same life-support as before the debridement, a sign that bacteria were still present. A doctor from the orthopaedic surgery team came to inform the family that the leg needed to be amputated. If they waited, the bacteria could travel into his groin. Kosokowsky escaped to the picnic table outside and sobbed.

The news of the amputation came just before Paulos’s mom, Maria, arrived. Her daughter, Paulos’s older sister, had died from melanoma in 1999, so everyone wanted the news to be good on her arrival. It wasn’t. When she heard that her son would lose his leg, she wept.

The doctors cut off Paulos’s leg just above the knee. Paulos’s abdomen was swollen-a complication called abdominal compartment syndrome-and ventilating him had become difficult. While Paulos normally weighed 165 pounds, he had ballooned to more than 200. Golan couldn’t wait any longer. He brought in two teams of surgeons-general and vascular-to operate on Paulos. They searched for signs of necrotizing fasciitis in the abdomen but luckily found none. The bacteria hadnt spread, and the swelling and infection were under control. There was nothing more the doctors could do. It was up to Paulos to survive.

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Paulos with his prosthetic leg
In the meantime, the ordeal was giving Kosokowsky the opportunity to interact with Paulos’s big Greek clan. They could see how much she cared. As days turned into weeks, Kosokowsky helped her boyfriend’s mother navigate Toronto. When Paulos went under, Kosokowsky was a stranger to his extended family; when he woke up, she could recite everyone’s backstory with impressive detail.

Not everyone was charmed. One of Paulos’s close friends cornered Kosokowsky in a hospital hallway. He had always looked out for Paulos and told Kosokowsky that if Paulos was lucky enough to recover from the surgery, he should be spared a broken heart. Kosokowsky stood her ground. “I’m not going anywhere,” she told him. “Sam lost his leg; he didn’t change as a person.

Paulos awoke on September 12, six days after being put on life-support. He was heavily drugged and unable to talk, but when Kosokowsky walked into the room, he turned toward her and smiled.

Paulos and Kosokowsky had loved to go out for dinner, explore the Queen West neighbourhood and stroll in silence through the Art Gallery of Ontario. Once Paulos had recovered enough to talk, he decided it was time for an important discussion.
“We won’t be able to do that anymore, at least not in the same way,” he said. If she wanted to leave him, he’d understand. Kosokowsky refused to consider it.

After 20 days in the ICU and four more in the orthopaedics ward, Paulos was released. Being in public was a crushing return to everyday existence. He hadn’t had time to adjust to his new reality: the stump where his leg had been, the scar stretching up his stomach, his diminished 136-pound frame. He was transferred to West Park Healthcare Centre, where Kosokowsky visited almost every day of his month-long stay. The process of learning to walk again was agonizing, and phantom pains made his foot feel as if it were trapped in a slowly tightening vise. Kosokowsky’s presence eased the loneliness of recovery. After he was discharged, Paulos moved into her place.
Over the next six months, he progressed from walking between railings to a walker, two canes, one cane, and then fully unsupported. With the help of insurance and family members, Paulos bought an $80,000 state-of-the-art prosthetic called the Genium. The leg featured a microprocessor knee, an accelerometer, a gyroscope and “stumble recovery” capabilities, all of which made walking much easier.

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The happy couple
In the two and a half years since his accident, Paulos’s relationship with Kosokowsky has transformed dramatically. When Paulos left for the cottage, everything was fun and light. Suddenly, they went through a test more harrowing than most couples will ever experience.

“The whole ordeal strengthened our emotional bond and definitely brought us closer together. I’m committed to Gayle fully, and forever,” says Paulos. Today, they’re not engaged, and that won’t change-Kosokowsky was married twice and has sworn off the practice-but they are in every other way bound to each other.

Paulos has had to adapt to a slower pace. He can’t jump out of bed in the night to get a glass of water. He must sit in a chair to shower and can’t run or drive standard. Simple tasks like screwing in a light bulb require more time than you might think, and he’s mindful of his other leg, which bears about 30 per cent more load than it did before the accident. He’s had to come to terms with relying on Gayle for certain chores, like shovelling heavy snow and bringing home a Christmas tree. In other ways, however, it’s as if nothing has changed.

“Gayle doesn’t treat me any differently,” says Paulos. “In the beginning, when my mom was around, she was always fussing, moving stuff, staying close in case I tripped-which I did appreciate. Now she worries less. On her end, Gayle considers me perfectly capable of doing most stuff on my own. She doesn’t look at me like I’m disabled. She looks at me like I’m me.”