By Mark Maske and Jason La Canfora
Washington Post Staff Writers
Friday, January 27, 2006
Brandon Noble needs crutches to walk, and he has been relegated to spending much of his time at home on his sofa. When he's lying in bed at night and needs to move his left leg to get comfortable, he must lift it with his arms or nudge it with his right leg. He struggles to play with his children.
But while Noble might have the typical limitations of a broken-down football player, the career of the Washington Redskins' defensive tackle isn't threatened by damaged ligaments or cracked bones. At 31, Noble has been sidelined by a staph infection, suffered after being injured, that in some cases is potentially fatal.
"It's been an incredible couple of years here," Noble said. "It's like I'm a modern-day Job."
For the second time in a year, Noble is being treated for methicillin-resistant Staphylococcus aureus, or MRSA, a sometimes debilitating illness that is becoming increasingly common in the general population, according to national health experts. It is a growing concern for the NFL, which has experienced a recent increase in MRSA cases.
The NFL has sent literature on staph infections to the league's 32 team doctors and trainers, and last February it arranged for representatives of the U.S. Centers for Disease Control and Prevention to address teams' medical staffs, according to Elliot Pellman, the chairman of the New York Jets' medical department who serves as the NFL's medical liaison.
"Certainly there is great sensitivity to the issue," Pellman said.
John Francis, an infectious disease research fellow at the Johns Hopkins University School of Medicine, said MRSA, which occurs most frequently among people in hospitals and other health care facilities who have weakened immune systems, has become a serious public health issue because its resistance to many commonly prescribed antibiotics makes it difficult to treat. "The effects are being seen and are a cause for concern not only here in the United States, but worldwide," Francis said.
MRSA can first appear as merely a small pimple and spreads like most infections, according to the CDC, through skin-to-skin contact, abrasions that become contaminated and exposure to contaminated surfaces. The working conditions for NFL players, who share locker rooms and training facilities with teammates and are involved in a violent game in which contact is commonplace, would be a likely breeding ground.
The Redskins have had five cases of MRSA in the last two years, the first at the end of the 2004 season, according to team physician Tony Casolaro. The team tested 120 players and coaches at the start of training camp last July for MRSA, but all were negative, Casolaro said. Similar statistics were unavailable for the NFL.
"Someone said, 'Oh Bubba, you've been in this business for 35 years, you've seen everything,' " said Bubba Tyer, the Redskins' director of sports medicine. "Well, I hadn't seen everything. This Brandon Noble case is the first one I've seen like this. So we'll continue to educate ourselves and educate our team and do the best we can."Frustrating Setbacks
The Redskins signed Noble as a free agent from the Dallas Cowboys in 2003, envisioning that the hard-working, no-frills player would anchor the middle of their defensive line. But he essentially shredded his left knee during a preseason game that summer. He didn't play at all that season, and even he acknowledged at the time that there was a good chance that he would never play again. But he didn't give up, and he rehabilitated the injury and played the entire 2004 season for the Redskins.
Last May, Noble underwent what was to be minor arthroscopic surgery on his right knee in North Carolina. The surgery was not performed by a Redskins team doctor. After returning home from the hospital, he noticed a red mark about the size of a quarter on his knee. The next day, the mark had grown to cover his knee and the following morning Noble awoke to find his entire leg discolored. His mother-in-law, Kathleen Hoyt-Dougherty, who is a nurse, examined the knee and told her daughter, Mary Kate, to immediately take him to the hospital.
"Our doctors took a swab of it and it takes 48 hours to get the confirmed test back that it's MRSA; and within 48 hours Brandon was already in the hospital," Tyer said. "So we didn't know that's what it was."
Noble was found to have a MRSA infection. At Sibley Memorial Hospital, doctors cleaned out his leg and drained a bursa in his knee, finding it to be full of pus. Noble had his knee flushed during a second surgery, and felt better the next day. He remained in the hospital for four days, receiving antibiotics and rubbing ointment in his nose daily.
Noble said Redskins owner Daniel Snyder and Coach Joe Gibbs visited him after he had been in the hospital for a day or two, when he was on standby for surgery and still was miserable. They walked into Noble's room about 9:30 p.m. and started talking to Noble's doctor. Noble had the bandage removed from his knee.
"It looked like someone was squeezing green mayonnaise out of my leg," Noble said. "It wasn't even oozing. It was like when you put your thumb over the end of a hose. I'm sitting here looking at Mr. Snyder and Coach Gibbs and they're trying to keep the conversation going with the doctor, and this pus is flying out my leg. It was gross, and they keep looking down and then looking up and I was ready for them to pass out. But I was on drugs. So I thought it was really funny, and the doctor thought it was hilarious. He talks about it all the time still."
His rehabilitation, he said, consisted of going to Redskins Park to have his knee iced, but even that wore him out. Noble was so weak as he recovered that he had to take a two- to three-hour nap every afternoon. Finally, he overcame the infection and rebuilt the muscles in his leg.
He returned briefly during training camp last summer, but suffered what was believed at first to be a minor injury in his left knee. He ended up having arthroscopic surgery in September, and the left leg became infected. "It looked like there was a football in my knee," Noble said. "It just ballooned up."
The infection got into the joint of his reconstructed left knee and essentially hid among the hardware and screws, making it harder to find and kill, Noble said. A little more than a month ago, doctors went into his left knee to drain it and clean the new infection. But they couldn't get all the pus out, so he underwent another arthroscopic surgery and remained in the hospital for another four to five days, beginning a new round of antibiotics. When Noble's doctors found out he'd had MRSA previously, he was placed in isolation, he said.
His wife delivered the couple's third child while Noble was in the hospital. His doctors were reluctant to allow Noble to be on hand for the birth of his son, but relented and permitted him to watch from a wheelchair in the back of the delivery room after he washed.
This infection is not quite as painful as the previous one, Noble said, but it's still quite uncomfortable. Noble's thigh muscles have completely atrophied, to the point that he feels like he is returning from reconstructive knee surgery all over again. His medication tears up his stomach, killing all the enzymes and bacteria in the stomach and intestines that aid in digesting food. When he tried to eat lasagna recently, Noble said, he could feel the sauce coming back up his throat. His weight has dropped from 299 pounds to 265 and his diet consists primarily of yogurt and bagels.
His symptoms are the same as they were when he had his previous infection -- a fever, chills, shakes and overall pain. He calls it "like having the flu, times 100." A nurse would come to his house to change his bandages and check his catheter, which allowed him to take intravenous antibiotics.
His newest infection has not been definitively diagnosed as MRSA, but Casolaro said Noble is receiving "presumptive MRSA" treatment. Noble has endured weekly blood tests to track both the infection and what effect his medication is having on his system.
Until yesterday, Noble was taking two antibiotics, one drug that kills anthrax and another that kills staph, he said.
"So my stomach is a disaster," Noble said. "They still don't know exactly what I have. They're just treating me for what they think I have, and it's definitely working. They've got me on stuff that'll kill a horse."
What scares him the most, Noble said, is that his doctors aren't certain how he got this infection. They tell him he could have gotten it from an infected stitch from last fall's surgery, but they don't know for sure.
"Maybe from my knee getting drained," Noble said. "And it can just float around inside of you unless they kill it with the antibiotics. It can go to your brain, your lungs, wherever, and there it is. They don't know how you get it and they can't tell you how or where. It's scary. It really is scary. . . . You wouldn't wish it on your worst enemy. . . . Every doctor I've been to, I'm like, 'How did I get this? Tell me how I got this, so I can not do whatever it was.' But they can't say. It could be in you. It could be on you. It could be next to you."
Francis said NFL players could face an increased MRSA risk.
"What would put an athlete at risk is contact, like in wrestling or football," Francis said. "A great deal of person-to-person contact is a risk. If a person has an open wound and it comes into contact [with an MRSA carrier], that is a risk. If people are in a locker-room setting and are using the same towels or the same whirlpool, that is a risk. Shared equipment would be a risk."
Nine cases of MRSA were found in a minor league baseball team in 2003, according to the Professional Baseball Athletic Trainers' Society. In eight cases an abrasion caused by sliding eventually became infected. All nine players fully recovered, though five faced a recurrence of MRSA the next season.
The most serious MRSA case in a football player occurred at the Division III college level. Ricky Lannetti, 21, of Philadelphia, a senior at Lycoming College and a wide receiver on the school's football team, died from MRSA on Dec. 6, 2003, in Williamsport, Pa.
Casolaro said Redskins with skin infections are treated with an antibiotic that can cover the MRSA bacteria, and often that medication at an early stage can be taken through the nostrils two times a day for 7 to 10 days. Tyer said all the MRSA cases on the Redskins other than Noble's were successfully treated with oral antibiotics.
Casolaro said that whenever there are any bodily secretions involved with an injury, "it is presumed to be contagious," by the doctors and athletic trainers, who also use an antibacterial rinse to treat abrasions.
"We culture every abrasion," to know how to treat it and "to know if it's MRSA or not MRSA."
He said the team has a physician on site every day during training camp, and four days a week during the season, and all keep an eye on any infection issues. He said the team's training staff also uses a special anti-bacterial soap found in hospitals.
The CDC's recommendations to the public for preventing staph infections apply to pro athletes as well: frequent hand-washing, keeping cuts and scrapes covered with a bandage, avoiding contact with other people's wounds and avoiding sharing personal items like towels and razors. And health experts have long warned that over consumption of antibiotics can lead to the development of resistant strains of infection.
"The locker-room environment is full of bacteria," said New York Giants center Shaun O'Hara, who suffered a staph infection that wasn't MRSA. "I think now I'm a little more conscious to use anti-bacterial soap and try to be on the lookout. If I see anything even remotely close to something I'm not used to seeing, I'm in the training room and I'm like, 'What's this? Let's take a look at this.' Usually, you think you're invincible. Once you get a dose of this, it brings you back to earth."
O'Hara's illness began with a calf injury suffered during a Sunday game in the 2004 season, he said. He practiced the next day and the following Wednesday. He was getting ready for another practice that Thursday when he noticed his leg was swollen, and a Giants trainer took him to see a doctor. His plan was to be back on the practice field by that afternoon. Instead, he spent five days in the hospital, missed two games and took intravenous antibiotics for about a month.
Noble said that athletic teams in all sports and at all levels need to be vigilant.
"You've got a lot of big guys -- sweaty, with cuts -- outside rubbing on each other," Noble said. "And it just gets passed around. It needs to be addressed, but I don't know how they can do it. The biggest thing, I think, is getting on it right away and getting it taken care of."Pondering a Comeback
For now, Noble doesn't change his newborn's diapers and rarely holds him because he's worried about his sweat touching him. He worries about his 4-year-old son, Conner, getting cuts when he plays outside. Any time his wife shows a symptom of illness, he thinks about his infection and whether she might have gotten it.
"I couldn't imagine having my children or wife go through it," Noble said. "That would kill me. . . . That Germ-X soap, I've got that everywhere in my house. I spray it on my kids. Every time they walk by, it's like, 'Give me your hands. Wash your hands off.' "
He goes to Redskins Park daily for treatments. He has been experiencing back spasms lately. Yesterday he said he had the 12-inch intravenous catheter removed from his right bicep. With the catheter gone he can now ride an exercise bike and begin getting back in shape. "I'm a free man," Noble said last night.
Noble hasn't completely given up on playing football again. He has one year left on his contract but is well aware that the salary-cap strapped Redskins could save $1.7 million by releasing him.
"My goal right now is to get off those damn crutches, and then after that see how I feel," Noble said. "If I want to come back and play, and if they'll at least give me an opportunity, then I'd probably try to come back. But I'd have to talk to my wife and kids first. I've got a 4-year-old and a 2-year-old and a newborn, and I've been on crutches two of the years my son's been born and pretty much my daughter's whole life. I've been gimped around, so it's taken a toll and my priorities have changed.
"But at the same time, I love the game and I love to play and I love being here, so the next couple of months or weeks or however long it takes me to make a decision will be interesting. I'm sure I'll go back and forth a few times."