Odors common to the profession

A beat-up old shack in ArizonaSomeone had changed the front door to one with windowpanes and added a chain link fence to the yard, but it was otherwise still the same dilapidated, dark, dusty shack with a rusty metal roof that I remembered from 35 years ago. The sheriff had stopped by the clinic and asked if I could go with him to investigate the place. It had been reported that groans could be heard coming from the building at night, and its occupant, a known diabetic, scruffy, bad-tempered, alcoholic male, had not been seen since leaving the local bar several nights before.

I was in my second year of family medicine residency at the University of Arizona and fortunate enough to be combining that training with a National Health Corps (NHC) assignment to this small, rural, desert town near Tombstone, AZ. Norm Castillo, D.O.’73, my fellow NHC assignee, and I were the only physicians (such that we were) for miles around. We ran the local hospital ER, delivered babies who were unable to make it through the birth canal at home on their own, and were also the acting county coroners. It was a violent place. We saw a lot of the sheriff and his deputies and were on a first-name basis with the ER nursing crew. It was also a requirement that we personally live there.

The sheriff and I arrived at the shack and, wanting to get the task over with, I got out of the patrol car first and moved to the door. I was about to rap on it when the sheriff put his hand on my shoulder and said, “Better let me do that, doc.” With his right hand on his holstered revolver in classic gunfighter style, he pounded on the door with his left fist, shouting loudly that it was the law knocking, and the door should be opened immediately. Nothing happened. More pounding and shouting following with the same result…but maybe there was a slight groan coming from inside somewhere.

With just four years of medical school and barely two years of residency, there was a smell I did not recognize, and my olfactory system would just not leave it alone.

The doorknob was black with an age-old patina of human fingerprints, and the cheap rusty lock was probably installed when Wyatt Earp roamed the area. On hearing the groan, the sheriff twisted the doorknob vigorously to the left and pushed hard on the door. It opened with a creak onto a dark, dusty room into which, with our sun-constricted pupils, we could not see more than five feet. He entered first, still holding his pistol, then turned his head away, wrinkled his nose and stepped aside to let me pass, saying, “Your turn now, doc.”

Through shafts of sunlight penetrating the dust I couldn’t see much, but I had been in medicine long enough to recognize at least some of the odors common to the profession. There was definitely a smell of old vomit. My nose followed this to the wall where I saw a smear of orange and yellow emesis at a height of about five feet that had dried while running down to the floor. There was a distinct odor of drying urine and human feces, which my eyes — now getting accustomed to the dark and dust — could see was in a pooling brown pile next to an ancient, gray mattress laying on a flaking 1950s vintage linoleum floor. On the mattress was an emaciated old male of Mexican heritage who was breathing, but that was about all. The sheriff, having released the grasp on his gun in order to hold his nose, had now retreated, apparently having decided it was the door we just came through that really needed his protection.

I took all this in and started to wish I was somewhere else. But my nose was still sniffing. With just four years of medical school and barely two years of residency, there was a smell I did not recognize, and my olfactory system would just not leave it alone. It had a kind of sweet note, combined with rotting fried chicken, sort of like a hot day on the south side of a north-facing fast food restaurant that specializes in an old military officer’s secret recipe. By now — some primitive reflex having taken over — I was sniffing all over, more like a dog than a doctor. I started thinking about diabetics in ketosis and the fruity smell of the breath that patients with that condition were supposed to have, but it was definitely not apples or oranges I was smelling here. The odor was worse closer to the floor and perhaps the mattress, but even if ketones, it was not coming from the derelict’s head…further south, perhaps.

Then I noticed he had on some socks that had been white at some very distant time in the past but were now gray and slightly wet. That seemed really odd. This was the desert, after all, a place where water would evaporate on the floor before your eyes.  I touched the socks to confirm my observation. The tactile sensation was, well…squishy, and there was a slight sense of popping bubble wrap, plus a revolting explosion of the mystery odor. I wished I had gloves on as the gooey, semi-clear liquid with all its stench penetrated the pores of my fingers. I got the right sock off and could see a badly stubbed first toenail, then a black foot, a purple ankle, blue lower leg and cold, paper-white skin above that disappearing up into the man’s filthy jeans. While trying to feel for a pulse near his ankle, I brushed off a swarm of black houseflies, but all I could feel with my now-slippery wet fingers was again the crackling sense of bubble wrap.

As a medical student, you learn all kinds of separate pieces of information from different sources and then spend the intern and residency years trying to connect those dots. The dots were slowly connecting for me when I suddenly had an epiphany: Although the medical school professors told us we would never see it, this had to be “wet” gangrene just like the Civil War surgeons described over 100 years before. And gradually, I started to think diagnostically like the highly skilled doctor I was hoping to become: alcoholic, poorly controlled type I diabetic, with peripheral neuropathy and poor distal circulation, left the bar thoroughly drunk, injured his toe on the way home; while sleeping off the alcohol, developed diabetic ketoacidosis, causing an even further prolongation of unconsciousness; clostridia perfringes must have contaminated the wound and with very little oxygen a perfect anaerobic culture media was created; the population of the deadly gas-producing bacteria had grown exponentially, producing the sub-cuticular gas that explained both the odor and the bubble wrap sensation that I knew was properly called “crepitus.”

That was what all those medical texts said would happen, but, unfortunately, not all nicely concentrated in the same book, chapter or paragraph.

I told the sheriff to call the ambulance and announced — somewhat proudly — that the patient was in a diabetic coma and also had gangrene in his right leg extending to at least the knee. He would need hydration, insulin and probably an amputation above the knee, but if we moved quickly, he just might survive.

And looking at the beat-up old shack again now 35 years later, my recollection is that is exactly how it turned out.

Kevin Ware, D.O.'73

After logging 25 years of full-time emergency room and office-based medical care, Kevin E. Ware, D.O.’73, ABFM, AAFP, continues to practice part-time while also working as a professional pilot. He resides in Mount Vernon, WA.

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