Thursday, May 13, 2010

Random Reflection on a Thursday: Maestro Moves and Jedi Nose Tricks

"Fruity. ..ah, yes indeed."


"Hmmm. . . .fruity. . ." I overheard one of the senior Infectious Disease attendings say one day on the wards to a medical student. He waved his fingers around his nose in circles like a maestro, and then nodded his head. "Pseudomonas," he then said with the kind of confidence one uses when they tell you the sky is blue or the grass is green. Pseudomonas.

The student looked from left to right, and then did a quick scan of the area. She shrugged and looked back at the attending with a puzzled expression. I could tell she wanted to say, Huh?

Here's the thing: It's not like I overheard this exchange in or even near a patient room. This all went down at the nurses' station, easily thirty feet or more away from the nearest hospital bed. The Infectious Disease consult team had just emerged from the stairwell and had made a pitstop right by where I was writing my patient notes.

The minute I caught a glimpse of the senior faculty member leading their team of five other people of various levels of training, I immediately placed my pen down. Some of my best medical knowledge acquisitions have taken place via eavesdropping around the I.D. team. (Matter of fact, I'm convinced that this alone scored me at least four correct questions on my board recertification but I digress. . . . .) No matter where you trained, everyone knows that you can always count on the I.D. doctors to drop some random clinical pearls of wisdom even in idle chatter. And don't let it be one of the senior gurus--it's a veritable mother lode.

"Do you mean fruity like when people have diabetic ketoacidosis?" the student inquired. Nice, I thought, but clearly a rookie suggestion. Nice, though. I rested my chin in my hand and buckled my seatbelt for the ride.

You could tell that the ID Maestro was already foaming at the mouth with the beautifully packaged teachable moment he'd just been handed. He smiled wide. "No. . . this is a different kind of fruity. Almost like. . .a pleasant strawberry smell. Very distinct and quite different from that chemicaly-fruity smell that's often appreciated in ketoacidosis. This is more. . .how can I describe it. . . .fruity-fruity." Chemicaly-fruity? Fruity-fruity? Man, I can't wait 'til I'm senior faculty.

So, for my non-medical friends, I don't need to tell you that the hospital is teeming with all sorts of smells. When someone says "hospital smells," most layfolks probably think of typical unpleasant odors like vomit or urine, shuddering at the idea that hospital personnel are pretty much desensitized to such things. The truth is that, yeah, we are pretty much desensitized to the fumes of bodily excrement; matter of fact, those don't even count as "hospital smells" because they're a given. I'm talking about the other smells. The ones that no-way, no-how would the average person be able to assign an origin other than, "Sheeesh! What is that?"

Sometimes they waft by and disappear like vapor, and other times they accost you and tackle you to the ground. Most will tell you that the longer you work in the hospital, the more discerning your snout becomes (at least that's the going line we give to students.) To some degree, I'd say that's true. For example, the smell of a bloody bowel movement is one you only need to experience one time to get the gist of, but over time gets fine tuned. I'm pretty sure that some of my gastroenterologist friends can tell you just how much blood and even how many units of blood you'll need to transfuse to bring the blood count back to normal--all with one whiff.

Then there are the more sophisticated ones like the one the Maestro mentioned. That "fruity-fruity" business to which he referred often accompanies wounds infected by a kind of bacteria called Pseudomonas. "Chemicaly-fruity" notes might emanate from the diabetic patient whose sugar situation has gone horribly wrong. The question is, how does one learn this? I mean, it's not like anyone ever gives you a lecture in med school that involves smell-o-vision. Does the scent portion of medical knowledge comes with time, skill and experience? Does it?

I lifted my nose skyward and inhaled. Fruity? Nope. I couldn't smell anything. I inhaled again. No fruity, no fruity-fruity, no chemical-fruity--no nothin'. I took a few more careful, inconspicuous nasal breaths inward, this time flaring my nostrils. Still got nothin'. I decide that I will immediately stand and sniff in the same place where the Maestro is standing the minute he leaves.

Turns out I wasn't the only one with faulty senses. "I can't smell anything," spoke one of the fellows (fellow = specialist in training) on the consult team. He squinted his eyes, inhaled, and then shook his head. "Nope."

The Maestro waved his hand again welcoming the scent to his nares once more (which I am totally going to do when I am senior faculty whether I smell something or not.) "You can't smell that? That fruity scent? It's so distinct," he querried emphatically. "Like strawberries." Uhhh, or not.

After a few more moments of smelly chatter, the ID team disappeared into a patient room. I quickly jumped out of my seat and stood in the Maestro's exact place. Big inhale. Wait for it. . .wait for it. . . Nada! Another big inhale. Nothin'. Dang.

Fifteen minutes later, the ID consult team filed out of the room and immediately formed a semicircle around the Maestro (who was in the midst of an infectious disease teaching symphony.) "That odor is classic. Any time you smell that coming from a wound, think Pseudomonas. And that green exudate! Classic. Great case."

"But you smelled it the minute we stepped out of the stairwell! You didn't even need to see the pus in the wound!" said the student incredulously. "Once we removed the dressing I could smell what you were talking about, but how did you notice that from all the way over there?"

The Maestro offered a knowing smile, kind of like Yoda in Return of the Jedi. Because I am the Jedi Master, Young Luke. (At least that's what I thought he should have said.) Instead he leaned on the nurses' station and replied, "After a while you just sort of know. I guess it comes with experience." (Told you that's what we tell the students.) They exchanged a few more comments/teaching points and then left to see the rest of their patients. Finally, the coast was clear.

I stood up and sniffed. I took two steps closer to the patient's room and sniffed again. Still nothing. Hmmm. Maybe 14.5 years out of medical school is not enough time to achieve Jedi olfaction. Hmmm. Suddenly, a thought popped into my head. It was from a discussion I'd had with my faculty mentor, Neil W. during one of our meetings. He was telling me about how more than once, he's literally had his nostrils quickly tickled with that chemicaly-fruity smell of diabetic ketoacidosis during fleeting 30 second patient encounters. Most of them were there for completely different reasons, but just one whiff was enough to change the game plan. That was all it took to make him stick the person's finger for a blood glucose and have his hunch confirmed. "The nose knows," he proudly said that day. That afternoon we debated for a half-hour about whether the clinical smell thing is a matter of Jedi-level experience or simply a skill that some folks are born with. (Yes, these are occasionally the kinds of discussions I have with my mentor.) The jury is still out.

The evidence.

When my kids were still in diapers, I can recall busting through the front door after rounding all morning and immediately yelling upstairs to my husband, "Babe! Who stinks? Somebody needs to be changed!" The first few times this happened, Harry protested and assured me that everyone was freshly diapered and poop-free. Without fail, I'd march into the playroom, pick up each boy and-- phew--quickly hit the stinky jackpot. "How can you not smell that?" (To which he'd just shake his head and walk away.) This has always made me wonder if mommies are somehow hardwired to detect diapers that have exceeded their expiration. Harry says this is just sho' nuff and bonified proof that daddies weren't meant to be the purveyors of poo diapers. I'm not too sure I agree with that, but the point is that just maybe the Maestro and my mentor aren't Jedi smellmasters after all. Instead, they might just be carriers of some bizarre snuffoluffogus gene. Kind of like the ones mommies get on their extra x chromosome that allows them to detect a poo diaper upon turning into their subdivision that the daddy sitting two feet away can't smell.

Sniff. . .sniff. . .sniff. . .sniff. . .

Eventually I found myself standing directly in front of the doorway that the Maestro and company had just departed. I knew that actually entering the room would border on a HIPAA violation, so this was the end of the road for me. I pinched my nose to get it ready and then took one last big sniff. Nose don't fail me now! Iiiiinnnnn--and . . . .wait! I smell something! I folded my arms and leanded toward the doorjamb taking one more whiff just to be sure. Undeniable. Like the Maestro, no further evaluation needed.

I looked down the hall to Mr. Stanley, the nurse caring for the patients in that room. "Um, Mr. Stanley?" I uttered once he looked my way.

"Hey there, Dr. Manning! You need something?"

"Uuhhh, I don't, but I'm pretty sure someone else does. Mr. Stanley, I think someone in this room needs to be changed." I gestured into the doorway with my thumb.

"Really?" he asked, "I don't think so, doctor. I was just in there."

I stuffed my notes in my pocket, stood up tall, and patted Mr. Stanley on the shoulder. Pointing to my nose, I laughed, "Just trust me on this one, Mr. Stanley. Trust me."

1 comment:

  1. haha so true! The other day I walked into a patient's room and the first thing I said without even knowing his name, "GI bleed?" I'm so glad my friend Kelly told me about this blog, it is such a great read. :)


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