Wednesday, April 2, 2014

Olfactory Adjustments

There’s no question that one of the most difficult things to get used to about the hospital is the smell — or, rather, the smells. This is especially true on a surgery service where many patients undergo multiple operations. Some need a leg or foot amputated. Others need open abdominal surgery and can’t control their bowel movements afterwards. Some patients’ intestines cannot absorb fat, leading to oily stools which give off their own distinct and foul odor. And still others have abscesses, or deep bacterial infections, which need to be cut and drained. It’s impossible to know how to react to the offending smell. Mostly, in the presence of these stenches, I control my desire to run from the room and, stoically, attempt to breathe through my mouth. But the smells are potent and dehumanizing. Empathy for these patients is difficult to find when one’s visceral desire is to sever the olfactory nerve which transmits smells to the brain. One encounter in particular is burned into my memory.

The Emergency Department had called the surgical team to see a patient who had a deep abscess. An abscess initially develops with some kind of break in the skin: an insect bite or a cut. And these infections are usually caused by specific bacteria called Staphylococcus aureus, though other bacteria can be involved. Our body’s immune cells wall off the infection, thus creating a pocket of pus and inflammation. Because it is walled off, antibiotics can’t reach the site of infection, so the only treatment in most cases is an incision of the abscess, draining of the pus, and allowing the incision to heal. If the abscess goes untreated, the infection, despite being walled off, can still spread. Some of these bacteria infect and consume flesh and produce gas as they disseminate.

The patient in the Emergency Room had a severe abscess that was far advanced. He had noticed a fever and some tenderness and redness in his lower abdominal area a week earlier but had not thought much of it. As the week went on, however, this area of redness grew and he decided to come to the ER. I felt awful for this young man who had assumed whatever this was would go away.

On entering his room, the smell hit me. There is nothing comparable to it. It took every effort to restrain myself from coughing — my sympathetic flight response had been turned on: my heart began to beat faster, I began to sweat, and I wanted to run. Never in my life would I have guessed that such an uncontrollable visceral reaction could occur because of a smell.

Alas, this seems to be a common theme throughout the history of medicine. Louisa May Alcott, author of Little Women, volunteered as a nurse during the American Civil War and wrote Hospital Sketches, a compilation of reflections on her time in the hospitals. She explains exactly how it feels to deal with the potent smells: “The first thing I met was a regiment of the vilest odors that ever assaulted the human nose, and took it by storm. Cologne, with its seven and seventy evil savors, was a posy-bed to it; and the worst of this affliction was, every one had assured me that it was a chronic weakness of all hospitals, and I must bear it.”

Our patient’s skin in the affected area was lucid. I could peer through into his body and I watched as air bubbles and pus percolated in the tissue. Because of the diffuse infection, he had to be taken to the operating room immediately in order for the dead tissue to be cut out. This was the only possible treatment — even with the medical miracles we possess, the scalpel is often still the best treatment.

In the operating room (OR), we put our masks and gowns on and the nurses coated the front of our masks with Starburst-scented cream to overpower the stench. We were like Alcott: “...armed with lavender water, with which I so besprinkled myself and premises.” Four of us — two medical students and two upper-level surgical residents — huddled over the patient’s body, cutting away skin and fat and flesh as warm pus poured out of the infected area, which overpowered the smell of Starburst, rendering our substitute for lavender water completely useless. But, there was no “out” here, no excuse to leave the OR. It had to be done, as the situation, in Alcott’s words, “admonished me that I was there to work, not to wonder or weep; so I corked up my feelings, and returned to the path of duty, which was rather ‘a hard road to travel’ just then.”

Thankfully, the patient ended up being ok — no vital organs were touched by us or by the bacteria. We had come very, very close to the inside of the pelvis with its reproductive organs, but all was safe and well. However, the smell lingers in my memory. Now, whenever I encounter an unpleasant smell in the hospital I compare it to the abscess. No smell is quite as awful and dehumanizing as the shock of the first one. Perhaps it was the unexpectedness of it that caught me. And, of course, I remember Alcott and what she must have faced in an understaffed, overburdened Union Army hospital in 1862. Her words admonish me that I am here to learn and help where I can and not to wonder or weep.

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