Friday Reflection 31: Senses, Memories, and Medicine

LT was an 80-year-old woman admitted to our inpatient medical team with gram-negative bacteremia. She came to the hospital with three days of weakness, fever, chills, and anorexia.

After briefly interviewing and examining the patient with my team in room 23 of the emergency room, I excused myself while they finished their assessment.

Sights and sounds and smells can be potent reminders of times past.

Smells are probably most powerful for me. Wet cardboard boxes reliably take me to the walk-in refrigerators of my family’s store that I worked in growing up. Perfumes can remind me of people I haven’t thought about for years.

Medical training introduced me to a whole menu of smells -- both diagnostic tools and reminders of times in my career.^[i] My third year of medical school began with a night in the operating room with a man with an aorto-enteric fistula. Years earlier, he had undergone repair of an abdominal aortic aneurysm. In the weeks before I met him, an intravascular infection had eroded through his aorta into his duodenum. That night introduced me to the smell of melena — a smell that I now can recognize even rooms away on a hospital floor, and which also takes me back to that New York Hospital operating room in 1991.

The smell of an anaerobic lung abscess reminds me of the estranged spouse of a colleague I once cared for. The acetonic smell of alcoholic ketoacidosis recalls two times in my life. Walking into a room filled with the odor of the metabolic acidosis of alcohol intoxication recalls images of the hospital room, also during medical school, in which I first learned the importance of the smell. I also remember how, when I first encountered this smell in the hospital, it reminded me of the smell of a friend’s room on too many mornings. When I learned what the smell signified, I realized, probably years too late, the severity of his drinking problem.

Sounds aren’t quite as powerful as smells for me, though it did take years for me to suppress the reflex of reaching for my belt every time something — anything — beeped. The Rolling Stones’ Exile on Main Street brings me back to painting my room with a friend when I was 14 and the Clash’s Combat Rock reminds me (for better or worse) of a girlfriend during year 10. The band Destroyer recalls terrible memories. A patient of mine introduced me to the band, but their sound became inextricably linked to a memory a few years later when I visited him in the ICU. He was being kept alive, awaiting organ harvest, after a suicide attempt. His family had left a radio with his favorite band playing.

When smells and sounds, as well as sights, come together, the impact of an entire location can be powerful. A handful of patients have left my practice because they could not stand seeing me in my usual office. This had nothing to do with the care I provided or the corporate art on the walls. They just found intolerable visits to a room that had been the site of some of their most painful memories.^[ii]

I once had a patient who actually abandoned her car in our hospital garage. Her husband, sitting in the passenger seat, had suffered a cardiac arrest while she drove him to the hospital. She could never imagine sitting in that driver’s seat again.[iii]

During a visit to my mother soon after my father had died, we began the usual walk from her apartment to the uptown subway. We had done this walk together innumerable times. It was the walk she accompanied me on when I was 12 and about to begin taking the train to school by myself. About halfway to the stop, she made an unusual detour.

“Where are we going?” I asked.

She replied, “Your father’s oncologist was on this block, I just can’t walk it yet.”

Back to where I began with LT. She was a kind and professionally accomplished 80-year-old woman. She had gram negative bacteremia with mild sepsis originating from a urinary tract infection. It was an unremarkable admission, the kind of case that a medicine intern should be able to manage by October, the fourth month of internship. What made the admission memorable was that LT was lying in room 23. Room 23 was the room my mother ended up in during her last admission to the hospital. It was in room 23 that she and I sat quietly — somewhat hopelessly — amid the dawning realization that her health was only going to get worse. It was in room 23 that she first raised the possibility of hospice. It was in room 23 where she began to recount the positive aspects of her final years.

I certainly could have watched my team finish their assessment of LT. I wasn’t sad standing in the room as a doctor years after I had sat there as a son. But I was distracted, revisiting those difficult weeks and recalling where they began.

Our senses, like our memories, define who we are. Doctors in training learn to use their senses to make diagnoses. All of us can be transported by sights, smells, and sounds.

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^[i] This is one of my favorite slides about the diagnostic smells.

^[ii] I have written about this before.

[iii] “Don’t worry” she reassured me “the car was a piece of junk and I took the plates off.”