Sunday, February 9, 2014

Scent of a Night Clinic

                   

“Oh my god, what is that smell?” Miss James exclaimed as I walked into the clinic. She sniffed me up and down.
“What did you do? Douse yourself with old sweat and then put on a pair of forgotten scrubs from the back of your gym locker?”
“It’s not that bad,” I responded as she sprayed me down with FOE (Fecal Odor Eliminator).
“It’s worse than bad. You’ll make our patient’s sick just by walking in the room,” she commented as she continued to spray. “Why didn’t you clean yourself up?”
“Well…I was out running and got back late and I’d forgotten I was scheduled to work tonight and then I only had time to throw on some scrubs and I guess the ones I picked out were already dirty and here I am.”
Miss James smiled and then started to laugh. She sniffed me again.
“A little better, almost tolerable. Hold on a minute; I think I know I have a solution.”
She left me alone and then came back with some clean scrubs; scrubs  which were hot pink and almost see through.
“Put these on,” she commanded.
“I can’t wear these,” I protested.
“Well you can’t take care of sick people smelling like a sewer. Come on, at least they’re size large. You’ll feel much better, I promise and you’ll look extra sexy.”
She gave me a leering smile and I acquiesced. Actually I didn’t look half bad.
“Pink is definitely my color,” I observed as I modeled my new couture for her.
“Enough of the runway show,” she stated. “There’s a patient in room one. Diabetic, short of breath.”
“Work, work ,work, that’s all anyone cares about around here. How can a few sick people compare to the world of high fashion,” I murmured as I picked up the chart outside the exam room.
“Darrell Preston, 23, diabetic since age ten, takes a lot of insulin,” I read.
I opened the door and began my introduction, “Good evening Mr. Preston, I’m Dr. Barnes, what is the problem that brings you in here?”
He was thin, African American, wearing a hot pink tank top and tight fitting blue jeans. He was sitting on the exam table, no he was curled up in the corner of the exam table, his arms folded across his legs which were pulled up against his chest. I was greeted by the distinctly fruity scent of ketones.
He looked up at me with a blank stare and groaned.
“Don’t say another word, Mr. Preston. I’ll be back in a moment.”
I stepped out into the hall and started to call for Miss James, but she appeared as if she had read my mind.
“I’ve already called for an ambulance. I just saw his blood sugar, 585.”
“As soon as I walked into the room and noticed the odor I knew it was DKA; that unmistakable fruity smell. Start an IV of normal saline and run in a liter wide open. Do we have the rest of his BMP?”
“Potassium is 5.3, everything else is normal.”
“Get an insulin drip going at one unit per hour, also.”
She went to work while I went on to the next patient, Shayla Bakerstreet, abdominal pain, nausea and vomiting for one day, 44, previous hysterectomy. Blood pressure 110/45, heartrate 120.
“Good evening, Miss Bakerstreet. I’m Dr. Barnes, what brought you in here tonight?”
She looked “sick” with flushed cheeks, long, matted brown hair, sunken eyes and a protuberant belly.
“I’m sick,” she announced, stating the obvious. “I started vomiting yesterday, my stomach feels like it’s about to explode, I can’t go potty; isn’t that enough?”
“It is,” I replied. I moved a bit closer and the fetid scent of her breath almost drove me back. The typical feculent odor of a small bowel obstruction filled the air.
“How long ago did you have the hysterectomy? And, have you ever had a similar problem before?”
“Ten years ago and no. I’ve never felt like this, ever,” she stated emphatically. “Can’t you do something?”
I lightly touched her abdomen and she winced in pain.

“I’m going to throw up,” she announced as I started to back away and then moved to help her sit up.
I reached for the basin by the sink and as I gave it to her she vomited, her emesis shooting out several feet and drenching me from chest to knees in vile, sewer like vomit.
I can’t get a break.
“Wait here, Miss Bakerstreet. As you can see I need to see if I can find a change of clothing.”
“It’s OK, I feel better after throwing up.”
I went back to the break room and called for Miss James. She had just finished loading Mr. Preston into the ambulance.
“Oh my god, what happened?” she asked and then she began laughing, uncontrollably, again.
“Yes, yes, very funny. Now is there anything else to wear?”
I had already removed the soiled scrubs and had wrapped a towel around my waist.
“Wait here, I’ll see what I can find.” And she left.
The TV was blaring as I sat alone in my slightly damp underwear, debating whether to shed them also.
“...lavender killer still at large. Victim number eight was discovered today in the posh Evergreen Hills suburb. Similar to the previous seven murders, the victim’s throat was cut with almost surgical precision. And, like the other victims, the scent of lavender filled the air at the crime scene . Police have been unable to find any bit of evidence which ties the victims together or demonstrates any sort of pattern…”
Miss James reappeared with a bright purple scrub top and some gray overalls.
“These are all I could find. I don’t know if it’s a step up from hot pink, but it will have to do.”
I eyed my new attire up and down.
“Beggars can’t be choosers,” I murmured as I pulled the purple scrub shirt over my head, stripped off the dirty underwear and donned the overalls.
“Let’s hope no one looks too closely, nurse. I don’t think this outfit hides everything that is supposed to be hidden. You don’t have a belt, do you?”
“I think I have something in my locker, hold on and I’ll get I for you.”
She returned in a few seconds with a bright yellow belt.
“I think you’re ready for the circus, all you need is a big red nose and some floppy shoes,” she commented.
“Fun-ny,” I remarked. “I’ll put on this white coat and I’ll be fine.”
The coat was a bit small for me. I gazed at my reflection in the mirror: my hair was a bit tousled, the small lab coat made my stomach appear to stick out, I was a kaleidoscope of color in my mismatched outfit. Miss James was correct, I was ready for the circus.
Perhaps my unusual look will bring a bit of lightheartedness to the clinic.
“There’s a sick baby in room 4, tempo 103, diarrhea, runny nose. Could be Rotavirus, there’s been a lot of that going around.”
“Thank you, nurse, I guess it’s back to work.”
I picked up the chart. David Thompson, 3 months old, otherwise healthy. Heartrate 130, temp 103.
“Good evening, I’m Dr. Barnes,” I introduced myself. “This is David?”

The woman with him, his mother, I presumed, nodded.
“What’s the problem little David is having?”
“He’s been coughing and vomiting and his bowels are running and running.”
“Is he usually healthy? I mean has he been sick or in the hospital before?”
“Never even been in the hospital. He was born at home and got all his shots at home. He started getting like this yesterday. I gave him some Tylenol, but he’s still sick.”
“What have you tried to feed him?”
“Why, breast milk, of course; greatest thing god ever made, at least for babies.”
“Can’t argue with you on that.”
I gave her a little smile as I started to examine her child.
“Let me look at your eyes, little David,” I whispered. He stared at my face, his eyes wide open. The pupils looked normal and there were tears. I listened to his heart which was racing along at about 130 and his lungs were clear, the only noise was a bit of a rasp from his upper airway which went away after he coughed.
“I’m going to undo his onesie and his diaper now, if that’s OK with you,” I asked softly.
His abdomen was soft and there was no tenderness. As I started to check his genitalia he did what all baby boys seemed to like to do to me and peed all over my purple shirt and then on my face as I tried to avoid the yellow stream.
“He should be a fireman,” I commented as I wiped urine form my face and chest. “I’m not having much luck with my clothes today. At least it’s sterile.”
I turned him to inspect his back and he passed a large, green diarrheal stool which ran onto his diaper, the exam table and onto my shoes.
“Figures,” I muttered. “Miss James,” I called out, “could you give me some help, please.”
In a few moments the door opened and my nurse entered, took one look at me: my purple scrub top was splattered with the spray of urine, there was baby poop on the table, floor and my shoes as I held our small patient in one hand and tried to clean up with the other. Miss James did what any conscientious nurse would do in such a situation: she burst out in uncontrollable laughter, for the third time.
“Dr. Barnes, you really should take greater care to control your bodily functions,” she remarked as she took our young patient from my hands and handed him back to his mother, who immediately diapered and dressed him.
“I’m sorry, Mrs. Thompson, it’s been one of those nights,” I apologized. “Little David has all the symptoms of Rotavirus, which has been going around recently. Be sure to give him plenty of fluids. We have some samples of Pedialyte here and I think that would be good for him. He should start to get better in a day or two. If he is unable to hold anything down, take him to the Pediatric Clinic at the University Hospital or bring him back here. Do you have any questions?”
I’m sure the look on my face was enough to deter any attempt at questioning my medical judgment or instructions. Miss James gave them a twelve pack of Pedialyte and some information on caring for babies with Rotavirus while I cleaned my shoes and rinsed my shirt.
I returned to work and was greeted by Miss James emerging from exam room one looking white as a ghost and holding her hand over her mouth. As the door closed an overpowering stench wafted through my nostrils and almost caused me to join my nurse who was now violently retching in the sink. The smell of fetid stool was filling our clinic, threatening to send all of us out into the street.
“I’ll open the side door, you get all the windows,” I shouted as Miss James composed herself. The cool night breeze helped to carry away some of the foul odor while my intrepid nurse attacked it with a steady stream of F.O.E.
“Perirectal Abscess is draining in room one,” Miss James announced.
“I could have guessed, you know. Now all the mystery is gone,” I replied. “It’s things like this which make me glad I broke my nose in the fourth grade.
I looked at the chart outside exam room one. Eric Miller, twenty nine, complaining of pain in the butt, otherwise healthy.
“OK, wish me luck. I’m going in,” I informed Miss James.
“Wait,” she said, putting her hands on my shoulders. She reached up and gave me a kiss on my cheek. “For luck, in case you don’t return.”
I smiled and then answered her kiss, “If I should fall in combat, please remember me; remember that I gave my life to the neverending battle against pus.”
I took a deep breath and opened the door.
“Good evening, Mr. Miller,” I greeted my patient by extending my hand. “What’s the problem you are having.”
Even though I was making a conscious effort to breathe only through my mouth, the powerful odor still managed to find its way into the olfactory centers of my brain. I summoned all my will power, commanding my dinner to stay put as I faced Mr. Miller.
“I’ve got this terrible pain in my rectum, for five days,” he reported. “It started draining a little bit two days ago.”
“Is that when this powerful smell started?” I inquired.
“I guess so, although I don’t really notice it much,” he stated, although I couldn’t see how he could not notice it.

“Well, let me look at your bottom, although I’m sure you should be at the hospital. You’re going to need surgery, at least an I&D.”
“I&D?”
“Incision and drainage of the abscess I’m sure you have. It will make you feel better right away,” I explained as I examined his perianal area and confirmed my diagnosis, all the time struggling to breathe.
The entire posterior and left side of the perianal area was red and hard, except for a black area in the middle. And, I was sure I felt some crepitance suggesting a particularly nasty infection.
“Are you diabetic, Mr. Miller?”
“Not that I’ve ever been told. But, I haven’t been to a doctor in years.”
“Did the nurse take any blood for testing?”
“No, but she didn’t stay in the room very long. She sort of looked sick.”
“Yes, she’s not feeling all that well for some reason, maybe it was your special cologne. Anyway, I’ll draw some blood for testing, but we need to get you to the hospital. Should I call an ambulance?”
“I’ll drive myself,” he decided.
“Good idea, you’ll get there faster. I’ll call the surgeon on call and have a crew standing by to take care of you. Good luck.”
Miss James had recovered and we managed to get Mr. Miller off to University Hospital with minimal fuss. Steve Johnson was on call and he told me he’d have his residents standing by to tackle what I was sure was a case of Fournier’s gangrene, although Mr. Miller didn’t really look very sick. We did do a fingerstick glucose before he left and found it was 350.
A tough way to find out you’re diabetic.
The powerful scent of infected necrotic tissue lingered in my nose as Miss James I had a brief respite from our duties.
“Vomit, poop, piss and pus; I’d say it’s been a very fragrant shift, don’t you agree, Nurse?”
Miss James was only barely recovering from the ordeal and gave a faint smile. The pungent scent of Mr. Miller still lingered in the air and my feeble attempt at consolation only made things worse.
“It’s not that bad anymore. Maybe there’s something else making you sick?” I queried.
“I’ll be OK. I think I’ll lie down for a few minutes. At least until another patient shows up.”
“Fine, I’ll man the front.”
I sat at the reception desk studying the latest treatments for stage four lung cancer when an older man walked in. He looked familiar, perhaps he had been a patient in the past.
I glanced up from my journal as he signed in: M. Adams, headache. The name struck a chord in my brain, Maurice Adams as in Dr. Maurice Adams, Cardiothoracic surgeon who had retired only a few years ago. His name still struck terror in the hearts and minds of medical students and residents. He had been famous for grilling underlings rotating through his service on the finer points of anatomy and physiology.
“Just a few minutes, Dr. Adams and,” I hesitated a bit, “these forms need to be filled out.”
“Of course, young man,” he answered as he took the clipboard and sat down in the lobby.
From my vantage point behind the reception desk something about him didn’t look right.
Of course something’s not right, that’s why he came to the Clinic.
He looked gaunt and old, not the vigorous surgeon I remembered. Miss James came up front at that moment and took over. She looked much better, the usual color had returned to her cheeks and she even managed a smile for me.
“That’s Dr. Adams. I know him from University Hospital, he was their number one heart surgeon until he retired a couple of years ago. There was some flack about him when he left, but I don’t know any details.”
“Well, he certainly smells better than all the other patients we’ve had today,” she observed her nose capturing the fragrance I had missed, a flowery smell which was very appealing.
“I’m not sure what it is, but it is very pleasant and soothing, like being at home” she said.
I must have looked confused.
“Spring floral. You should know it; it’s almost the same scent as those air fresheners I keep in the bathroom.”
I nodded in agreement, embarrassed because I had never noticed any air fresheners.
I took a short break while Miss James ushered the eminent Dr. Adams into exam room one. I glanced at his paperwork:
“Maurice Adams MD, FACS, seventy two, no allergies, no meds, no previous surgery, smokes occasional cigar, retired.”
I knocked on the door, waited a few seconds then went in.
“Good evening Dr. Adams. I’m Dr. Barnes. You probably don’t remember me, but I rotated through your service five years ago. What can I do for you.”
He eyed me up and down before answering, “Oh, yes, Dr. Barnes. I see you managed to graduate medical school, even though you once cut out one of my knots and I had to start over.”
“You remember, sir?” I’m sure I was turning red at the mention of my past misdeed. “I’m sorry about that sir. I was just a third year student. But, what about you? What’s the problem you are having?”
“I see you went into Internal Medicine, good choice, you’ll cause less mayhem.”
I was beginning to grow a little impatient. “What about you sir? It says you’re having headaches.”
“Oh, yeah,” and he pressed his hands against each side of his head. “They’d almost stopped until you reminded me. I couldn’t sleep, my head was pounding, like someone had hammered a seven inch spike into each ear. I took Acetaminophen, Ibuprofen, Tramadol, oxycodone and nothing helped. I was on my way to the hospital when I saw your sign, so I thought I’d stop here instead. Thought it might be quicker.”
“Well, you are right about that, sir. And, I have to say that after an endless stream of patients reeking of poop and vomit, your cologne is a breath of fresh air. Now, besides the headaches, any other medical problems?”
“That’s why I liked cardiac surgery. Just blood, no encounters with the greasy shit pipe or mucus. Just nice, clean blood.”
“Your health, sir,” I tried to direct him back to his problem.
“Nothing, no meds, no allergies, only rotator cuff surgery to fix  an old golf injury.”
“OK, let me take a look at you.”
He winced and drew back as I moved closer to examine him. He closed his eyes and wrinkled his nose and then he took  out a small vial, unscrewed the lid and took a long sniff in each nostril. I recognized the scent as identical to the one we had noticed in the lobby.
I took out my flashlight to check his eyes. He kept them tightly closed.
“Does the light hurt your eyes?” I asked.
“A little,” he replied.
“OK, I’ll just look at them without the light.”
I put the flashlight away and he opened his eyes. The first thing I noticed was that his pupils were unequal. The right reacted briskly as I moved my hand away from it, while the left was larger and only barely moved. As I looked more closely there was slight asymmetry of the face with the right drooping.
“How long have you been having headaches?”
“Off and on for years.”
“Have they gotten worse recently?”
“I’m not sure. I know it was bad today and nothing helped. That’s why I’m here. Can’t you just give me a shot so I can get some relief? Then I promise I won’t trouble you again.”
“Just trying to be thorough, sir, like you taught me.”
I smiled at him, but he just stared straight ahead, as if I wasn’t even there, like his mind was off in another world.
“I think you should have an MRI, Dr. Adams, but, for now, I’ll get you a shot of Morphine…”
“No,” he interrupted, “Demerol, that works better for me. Usually 75 IV does the trick.”
“OK, OK, but you really need to see a Neurologist. I’ll call Dr. Joint and I’m sure he’ll see you tomorrow, even if it is Sunday.”
“Thank you, young man. Now…Demerol?”
It was more command than request and his insistent attitude made me wonder just a little about the circumstances of his “retirement.”
“The nurse will be back shortly,” I responded, but as I said this I saw that he was back to staring blankly into space.
I found Miss James looking like her normal cheerful self and asked her to give Dr. Adams the shot of Demerol and then went to the break room for a moment. As I rummaged around in the fridge looking for something cold to drink I heard a loud crash. I ran to the front and heard more noises coming from the exam room. I threw the door open and found Miss James being held by Dr. Adams, a scalpel at her throat.
“Stop right there, Dr. Barnes or I’ll finish what I’ve started.”
“Just don’t do anything foolish, Dr. Adams. We’ll do what you want. Just let her go.”
“Oh, I will, I will let her go, once I’ve put an end to her misery.”
I took a step towards them, but he tightened his grip on her and held the blade against her neck. At the same time I saw him wince and close his eyes for a moment. Before I could respond, however, he saw me and I took a step back. He wrinkled his nose and then he put the little vial to his nose and inhaled deeply. The floral scent reached my nose and filled the room.
“What is it, doctor? What is going on? You don’t know, do you, but I do. It’s the tumor, the one in your head pushing on your brain, filling it with ugly, violent thoughts, telling you to use your surgical skills for evil. You know I’m telling you the truth. You’re a doctor, you’re a surgeon, you don’t kill people, you save them.”
“Kill people? I’ve never killed anyone. I perform surgery on them, make them better. Unfortunately, sometimes the patient doesn’t make it. He winced again and took a sniff from the little vial.
“It’s unbearable,” he explained, “the smell, like feces and rotting garbage, night and day filling my head, sometimes all I can do is clench my fist and close my eyes until the worst passes. Lavender helps, it reminds me of my wife.”
“Dr. Adams,” I implored. “You can’t do this. You’re a doctor.”
“I was a doctor. Now I’m famous, now I’m the Lavender killer.”
He started to cut Miss James neck, a careful, deep, even stroke right over the anterior border of the sternocleidomastoid muscle. Blood began to pour out.
“She’s pregnant, you know; you’ll be killing her unborn child. Could you possibly live with that?” I screamed and he stopped. Blood continued to squirt out of the wound as he dropped the scalpel. I ran to Miss James, knocking the distraught Dr. Adams aside. I grabbed a box of gauze sponges and ripped it open and applied pressure to the open wound. Luckily, this seemed to staunch the bleeding.
“Quick thinking, Dr. Barnes. It looks like you messed up another outfit,” Miss James whispered, looking at my blood stained clothes.
The bleeding had stopped and I taped the gauze dressing in place as I called 911 to report the capture of the Lavender serial killer and to call for an ambulance.
Dr. Adams was crying uncontrollably as the police cuffed him and led him away. It turned out that he had a massive tumor which was pressing on the olfactory center of his brain. He died two weeks later.
Miss James had not suffered injury to any vital structures. She recovered uneventfully and was back in work in a few weeks.
“It was quick thinking to say that I was pregnant,” she commented after she was home.
“Well…I remembered that Dr. Adams about how he loved children, he was always very vocal about this during his operations. I figured that the conflict created by the thought of him killing an unborn child would at least get him to stop and perhaps give me the chance to intervene. I think it worked pretty well. I mean, you are still here.”
“And still pregnant.”