On Nov. 18, 2018, Washington quarterback Alex Smith was injured in the third quarter of a Week 11 game against the Houston Texans. The injury was severe. This is a first-person account, from Smith's wife, Elizabeth, to ESPN's Stephania Bell, of the untold story of what happened next. This piece originally published on May 1, 2020. Smith was released by Washington on March 5, 2021, and is now a free agent.
Warning: This story contains graphic images.
"Our first priority is we're going to save his life. And then we're going to do our best to save his leg. And anything beyond that is a miracle."
Alex isn't Alex anymore.
It's been 57 hours since my husband was carted off the field with a compound fracture in his right leg in a Week 11 game, but now it's Wednesday at midnight and he's not just an injured football player -- he's the patient who's drifting in and out of consciousness as doctors try to figure out what's wrong. Of course, I just want to talk to Alex. But he's ... he's not there.
They're thinking he has a blood clot, a pulmonary embolism. Then we're doing a cardiogram. Throughout the night, it's test after test after test. Alex's fever is through the roof. His blood pressure is dropping.
Everyone -- the nurses, the doctors -- every person is in this room and can hear me asking, "Is everything going to be OK?" They are saying, "We just need to find the root of the problem."
Finally, we learn he has an infection.
The doctors are telling me, "He's septic. It's in his blood. But we don't know what type of infection it is."
Dr. Steve Malekzadeh, one of Alex's trauma surgeons, comes in early the next morning. It's Thursday, Thanksgiving Day. He would tell us later he came in because he couldn't sleep. He knew something was off. He unwraps the bandages from Alex's leg, even though it had been unwrapped just a few hours before. At that time, it looked normal, at least as normal as post-surgical fracture sites look.
But now his leg is black. The blisters are huge. It's clear the infection is in his leg. It's something I couldn't fathom seeing in a war movie, only now it's my husband. It's my worst nightmare.
Dr. Malekzadeh says, "We have to go back. We have to take him into surgery again."
Alex's parents are there. The Redskins were in Texas playing the Cowboys that day, but Dr. Robin West, the head team physician, flew back from Dallas to join in on the surgery. I couldn't even tell you how long it was, but it felt like we were waiting for an eternity.
The doctors finally walk in, and they look defeated. Like they had opened Pandora's box. "He has a bad infection," they say. "There was colonization of the bacteria all through his soft tissue. We removed a big portion of the anterior compartment."
"What does this mean?"
"Well, we had to take off a lot of skin, a lot of muscle tissue."
"So, is it fine? Is it done? Is the infection gone?
"No. We have to go back tomorrow. And we're going to do it again. We think this looks like necrotizing fasciitis."
We all look at each other in disbelief. Necrotizing fasciitis? Like, flesh-eating bacteria? This was something I only knew about from reading about it online.
Now it's Friday, and they are going back in to cut out more tissue. Then, the cultures came back and, sure enough, it's necrotizing fasciitis. There is one really rare bacteria in his bloodstream, aeromonas hydrophila, a bacteria typically found in freshwater or brackish water.
So Alex has a flesh-eating bacteria that's eating away his at his leg. He's septic and, essentially, dying. We're being inundated with medical language. Family, friends, everybody is on high emotion.
And I just need some grounding. I need someone to sit me down and tell me exactly what's going to happen. I send Robin (West) a text and ask her if we can meet privately and talk.
We head to the cafeteria annex, which had become my private escape. I said, "Please, can you just break this down for me? My husband is laying here. And he's dying. And it's coming from his leg. I just need to know -- why can't we just -- cut it off? I need to know if I'm going to be able to leave this place with him with me. I can't go home to my children without him with me. We need to make sure he's OK."
And these were her exact words. I can still hear them.
She said: "Elizabeth, we're doing the best we can. And right now, our first priority is we're going to save his life. And then we're going to do our best to save his leg. And anything beyond that is a miracle."
How'd we get here?
So let's back up a little.
Nov. 18, 2018, started out like any other home game day. Alex and I, we have a routine. He spends the night before the game at the team hotel. The kids and I, we wake up, do our breakfast, shower, get ready. We'll jump in the car, pick up friends and family in D.C., then head to the stadium. Right before I get to the stadium, Alex gives me a call. He's warming up on the field. We do our little pep talk. We always say the same thing, "Love you," then hang up. It's football, and though Alex is only 34 at this point, it's his 14th year in the league.
Everyone is tailgating and having a great time. We head into the stadium for kickoff. And that day was just like any other game.
Until, the play. We all stand because we realize it's Alex down. He's lying there, and I see that he grabs for his leg. I'm thinking, is it his ankle? Is it his knee? Our 7-year-old, Hudson, tugs at me. I look down and he's welling up with tears. He says, "Mom, the cart's coming." And he knows that when the cart comes, it's serious. To everybody else, this is a player that's down. Cart's coming. Game's gonna go on. But for me, our children, Alex's parents, this is more than that.
My in-laws take the kids, and I head to the tunnels. When I get down there, I hear screaming. In the medical room there are people crowded around Alex -- the doctors, [Redskins owner] Mr. [Dan] Snyder, all the medics. Alex screams as they try to readjust his leg. I've never seen him like that before. But in my mind, I'm just thinking, let's go. Let's get him on that ambulance, get him the surgery, get this fixed.
As we ride in the ambulance, Alex says, "Pull up the score. How's [Redskins backup] Colt [McCoy] doing?" He wants to know all the formations. This is typical Alex. He's worried about the team, which is still in first place at 6-3, and how they are doing. He wants to make sure everyone else is OK.
They are ready for us when we get to the hospital. There's a trauma bay open and they get imaging of his leg. Dr. Michael Holtzman is working that night. Dr. Malekzadeh is on call. Dr. West had said to us on the way in, "If you have any trauma, these are the best two guys you want working."
Before Alex goes into surgery, the doctors show us the CT scan and say, "This is a really severe fracture." It's a spiral fracture that starts down in the ankle joint and spirals all the way up through the tibia to the knee. And the fibula is broken. Because of the length of Alex's tibia, they are going to have to put in a few plates and quite a few screws. "It's pretty common practice," they tell us. "You'll go in there, maybe be in the hospital for two days, do a little bit of rehab and then you're on your way."
After surgery, the doctors say it went as well as they could have hoped and everything looked good inside his leg. The bones are lined up great. I even have pictures; it looks beautiful. Since Alex had suffered a compound fracture (a complex fracture with the bone breaking through the skin), they say there is a risk of infection. They had pulled out a little bit of dirty sock from the wound. But, he's on antibiotics.
Alex has a mild fever and is in a fair amount of pain the next day, but that was to be expected with a huge fracture repair involving three plates and 20-some-odd screws and pins. The doctors say they will probably keep him on some form of pain medication for the next couple of weeks, and we expect to head home on Tuesday.
But Tuesday afternoon Alex is still having a fair amount of pain and running a mild fever. Dr. West stops by to see him before she heads out of town with the team for a Thursday game. Dr. West says, "Why don't you just stay one more night?" Alex resists; he just wants to get home and sleep in his own bed, but Dr. West convinces us to stay. Thank goodness she did because that night he spikes a high fever.
Dr. Holtzman comes in the next morning and unwraps his leg and says it looks pretty normal. Blisters are normal, bruising is normal. But throughout that day, Alex gets progressively worse. By Wednesday night, well, we know we're not going home.
Saving a leg
The doctors make it their mission to save Alex's life and his leg. They say, "You know what? We're going to go in every single day." And for a week they go in every day for a debridement -- cutting skin, tissue and muscle -- until the infection is gone, until they're certain.
At night, I sit with Alex, not sleeping, and they come in with a pen, a Sharpie. And they write over his leg, where the infection looks to be tracking up. Every 20 minutes another resident comes in and writes -- it's coming up a little bit further. And eventually they take him into the operating room to cut into his thigh to see if the infection is actually moving up that high.
As I'm sitting there watching the infection move up his leg, I'm just trying to make sure that my husband's life is not in danger. I understand now, from the doctor's perspective, had they amputated at the time, it would've been above the knee. And it's a different quality of life whether you amputate above or below the knee.
Thankfully, the necrotizing fasciitis never gets above his knee. Alex still has his leg ... well, what remains of it.
After eight debridements, Alex has this completely exposed tibia. He has no anterior compartment. He is missing everything from his knee to his ankle and from side to side. The way the doctors explain his situation is Alex no longer has a sports injury. He has what would be more comparable to a military blast injury.
Alex doesn't look at his leg. He doesn't want to see it.
At that point, Dr. Vineet Mehan, the plastic surgeon, comes in with the orthopedic surgeons and says, "Here are your options. We want to lay out everything you could do."
For the first time Alex is really awake and listening.
"Obviously, one is amputating."
"Two is a muscle transfer. One transfer option would be your lat."
Alex said: "You're not taking my lat. I need that to throw. It's everything. You can't take my lat."
It had to be a large muscle because Alex's tibia was so long.
"We can take part of your quad on your left leg."
But they also tell him it might not work. In addition to transferring the muscle, you have to connect arteries and veins and all these things. It's microvascular surgery. And when you do that, like an organ transplant, it's not guaranteed to take. If it doesn't take, you're going to an amputation. And if you have an amputated right leg, now your left leg is weakened. You have to use that leg for the rest of your life.
"It's not to say that you couldn't be athletic and have a prosthetic because there are amazing athletes that have prosthetics," the doctors say. "But we wouldn't want to try that surgery and -- if it doesn't work -- weaken the leg that you would have to use for the rest of your life as the strong leg."
Alex's parents and I look at each other. "What do you do?"
Alex is participating more in the conversation, and he's a fighter. Give him a challenge and he wants to go. As soon as he hears about the transfer, he's like, "Let's do it. Let's go."
After the muscle transfer surgery and a week of recovery, Alex is finally discharged home in a wheelchair with his leg fixated upward. It's now two weeks before Christmas.
The first few weeks out of the hospital are hard. We had to outfit our house to be wheelchair-accessible for Alex to get around. He can't let his leg down. He needs help with everything, whether it be to get out of bed or go to the bathroom. He can't really shower. Alex came home with a PICC line, so I give him his antibiotics every day. The kids all want to care for him, too.
Every time I line up the meds for his shots, our daughter, Sloan -- 2 years old at the time -- helps me push the shots. Our boys help push Alex in the wheelchair. If anyone comes over, our middle son, Hayes, says, "Don't go too close to my dad's leg." He has hand sanitizer ready. They understand. They're just so excited we are all together again.
Once Alex starts bearing weight on his leg, he begins going to physical therapy five, sometimes six days a week. Some days he'll finish PT and say to me, "I think I want to head out to the practice facility and get a little more upper-body work in." His mental fortitude is ridiculous. He pushes himself every day.
It's absolutely incredible how far he's come.
Between the debridements, the muscle transfers and microvascular surgery, the skin grafts, the external fixator shortening and removal, and, finally, the replacing of the large circular bone-stabilizing frame with a titanium rod, Alex would undergo 17 total surgeries and endure four separate hospital stays over a period of nine months.
There's no doubt that this is a challenging time, especially for Alex. But through it all, he keeps great perspective. At one point when we're in the hospital, shortly after he came so close to losing his life, Alex tells me out of nowhere that everything is going to be OK.
"Do you know how many people would love to trade positions with me?" he says at the time. "Millions of people would love to be where I am right now. Do you know the life that we live and the blessings we have?"
"What?" I say, in disbelief.
"And we can't take it for granted, not even for a minute," he says. "Perspective."
I have to admit he's right.
As I think back on the experiences of the past 15 months, I feel so fortunate. We've had so much support from family and friends who helped us, especially with the kids, by just loving them and wrapping their arms around them. It's not to say that we weren't there, because they saw us every day. But they helped keep the kids' lives as normal as possible, which was so important to me. Early on there were many nights I spent at the hospital, and I became friends with a lot of nurses. And the doctors were amazing -- they genuinely cared. There were days we all broke down together and days we all cheered and laughed.
Alex and I joke that everyone wants their daughter to grow up to be Dr. West. Not only is she an incredible doctor, mother, woman -- she's a friend. Dan Snyder and the entire Redskins organization have been incredibly supportive throughout the entire process, ever since the moment Alex was injured. I don't think I could ever have imagined a better team than what we were given.
There have certainly been moments along the way that have reinforced the concept of perspective. Traveling to the San Antonio Military Medical Center in February 2019, for instance. What a humbling experience. It just put Alex's injury in a whole different light. There have been so many soldiers who have had this type of injury. And it is because of them -- not only fighting for our freedom but through their injuries, the medicine and the technology learned as a result of caring for them -- an athlete is reaping these benefits. It's incredible.
It may have been intimidating for Alex at first when we arrived. He said, "There are people here that are Army Rangers, Special Forces ... do you know what kind of badasses they are?"
They're doing things that an NFL player couldn't do. But they had that mental fortitude and that perseverance; they were going to get through it. And I think it gave Alex that extra little, "I can do this. I got this." I don't think it's easy for anyone, especially an athlete to go from the peak of your profession to not being able to walk. I think you need motivation to get back to that spot. To watch him light up, to get that inner drive again, it was pretty awesome. On the way home from San Antonio was the first time since the injury that Alex talked about playing football again.
When I think about Alex returning to football, there's part of me that wants him to do whatever he has the inner drive to do. If that means stepping back on the football field and throwing on those pads, then I want him to prove that to himself. But obviously there's part of me asking, "Is it worth ever doing that again? Do you know what we just went through?"
But, I know at the end of the day this is his fight -- physically, emotionally and mentally. I want him to have something to fight to get back to. And I support him.