“Listen Buster,” she said once, standing in the closet pinching her nostrils and pointing to the socks in the corner as if they were kryptonite and she was Superwoman. “I’m not picking them up any more. That baloney about not being able to smell works for you in the ER, but not here.”
The truth is that it really does work in the ER. I once had a three hundred pound man with a perirectal abscess that required incision and drainage. Being the nice guy that I am, I told the man that we would use conscious sedation. But that required a nurse to be in the room to monitor his vitals during the procedure. I couldn’t get any volunteers to hold his gluteal cheeks apart so I taped each one to a bed rail while I went about my business. I was attempting to hold a conversation with the nurse about the NFL playoffs. I don’t know if it was the methane released from the patient’s relaxed rectum or the anaerobic bacteria pouring from the incised abscess, but I have to admit that I did notice an odor. Suddenly, our conversation, which was mostly one sided anyway, was interrupted by loud retching. The nurse was on her knees over the wastebasket. I told her she could leave if she could find someone to monitor the patient. I saw a look of horror come over the face of a nurse outside the room who overheard my comment. She raced into another patient’s room.
I’ve always seen this talent of ours in metaphorical terms. Patients always clean up and look their best when they are going to see their private doctor. But emergency physicians see their patients on their absolute worst terms. And beyond the physical, how many times have you looked past something ugly, distasteful, even shameful in a person in order to hear their story, get to the bottom of the problem, and formulate a plan for healing? As much as each of us may dislike the habits that brought our patient into the ER – the gluttony leading to obesity, the drug abuse that leads to AIDS, the rampant promiscuity that leads to repeated STDs – you put all that aside to gain the patient’s trust, in order to deal with the problem at hand. It doesn’t mean that you don’t deal with the underlying issue. You just don’t let it get in the way of the current problem.
How many times have you been told by a stoic old man, whose wife made him come to the ER for his indigestion, “Oh, Doc, I’m just fine, I can go home.” You didn’t buy it, did you? It didn’t pass the smell test. You know that guy is going to crump in the parking lot. So you get another set of enzymes or put him in observation. And when his troponin finally comes up, you’re not surprised. You could smell that something wasn’t right about this one. And you were right.
I had an experience like that not too long ago. Everything was pointing one way, but I could just tell that there was more to the story. When the truth emerged and the problem solved, I looked clairvoyant. “I knew something wasn’t right.” I bragged to the nurses as I was recapping the night’s events. “I could smell something wrong.” I left work feeling like the offensive coordinator who called a screen pass just when the defense called the blitz. I was on top of my game.
As I entered the house I was treated to the aromas of frying bacon and freshly brewed coffee. Without prompting I launched into a full rendition of the night’s cases, including the astute detective work that I had done. I related all this, including the football analogy, to the glazed stare of my wife over breakfast. “I could just smell something wrong,” I said dramatically while looking off into space with a self-congratulatory air. I didn’t notice her slip away from the table as I finished breakfast and began drifting into thoughts of bed.
But just when the last aromas of coffee cleared by nostrils I was assaulted by the stench of garbage. Turning around I saw a big bag of wet garbage, tied up and sitting in the middle of the kitchen.
“Wha…?” I just looked at my wife in total bewilderment.
“I know that since your ‘basketball injury’,” she said while making quotation marks in the air, “you can’t seem to smell when it’s time to take out the garbage. So I thought I’d just give you a little visual reminder.”
“Gee, thanks, sweetheart,” I said wanly. I couldn’t tell if she believed me.