Olfactus amissio. Anosmia. For some it is a medical condition. But for
emergency physicians, it is a talent, cultivated through years of
practice. Who else can walk into the room of a patient who hasn’t
bathed in a month and say pleasantly, “Hello, I’m Doctor ___, how can I
help you.” The chief complaint from triage notes says, “smells of
urine,” followed by “complains of abdominal pain.” You look around and
the staff is spraying the air with that sickly sweet cinnamon smelling
stuff or wearing masks. But you and I, we are untouched by stink! It is
nothing to us! OK, sorry for the theatrical hyperbole, but you know
what I mean. Who else can look deep into a mouth that hasn’t been
rinsed with anything but cheap wine, feel armpits that have never seen
deodorant, remove socks that have taken on the form of crusty feet?
Nobody, that’s who.
My wife says it is a talent that came to me naturally. She heard stories from my mother about how she sometimes had no choice but to burn my clothing. I think it was a complete lie – one of those wife/mother-in-law bonding things – so I never contested it. The truth is that I could smell just fine until Tommy Miller decided to rearrange my face during a basketball practice. I played for a small college in rural Nebraska. And Tommy was on my team. But he didn’t like the fact that I was taller and could jump higher than him. So one afternoon, during a practice, he decided to go for a rebound that I was holding...with his elbow. He missed the ball but found my face. The local general practitioner repeatedly cranked on my face, then walked across the room to view my face until he and his nurse thought things looked straight again. Not until years later did a CT scan suggest that my simple broken nose had actually been an open Le Fort II fracture. I told my wife that my face had been moved back a few millimeters, damaging my olfactory nerves. That, I explained, is why I didn’t notice the smell of stinky socks left on the closet floor. She didn’t buy it.
“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.
That’s where the selective aspect of our sense of smell becomes so important. The truth is that our noses work just fine. We just choose to the turn the gain up or down as is needed for the situation. For instance (and don’t tell my wife this, I think she’s starting to buy the basketball story) I can smell the difference between alcohol and acetone on the breath. They say that a dog can smell fear. Well, I can smell a history that includes a lie. You probably can, too.
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.
CDR Mark Plaster, MC, USN Founder & Executive Editor of Emergency Physicians Monthly