Letters from Maine

The Nose Knows


The receptionist usually scribbles an abbreviated version of the patient's chief complaint at the top of the billing form to give me a heads-up on the diagnostic challenge awaiting me, but Sheila was still learning the job and had left the space blank. It wasn't a big deal, but it meant I was going to enter the examining room blind.

As I eased the door open, however, my nose told me everything I needed to know before my eyes met the droopy gaze of the 12-year-old slouched on the exam table. The heavy, sweet odor told me this young man's mother was going to say her son had a sore throat, and it told me I was going to correctly predict that his rapid strep test would be positive.

Although the ears and eyes are the pediatrician's most powerful sensors, there are a few pediatric illnesses with distinctive odors that can lead the olfactorily sensitive physician to the right diagnosis. When I check the incubator each morning, I know instantly by the smell if we have a positive urine culture growing. An 8-year-old boy's smelly armpits prompt me to examine his genitalia, even though his chief complaint is a cough.

There are the 3-year-olds with bad breath and a little trickle from one nostril whose parents are surprised when I accurately anticipate that I am going to find a smelly little treasure hidden beneath a turbinate. And I must admit that I get a bit of perverse pleasure when I see the expression on the face of a squeamish parent of a 1-week-old after I lift up a previously undisturbed umbilical cord and release an invisible fetid cloud of aroma.

Other odors can alert me to a child-unfriendly home environment. When a 3-month-old smells like an ashtray, I can skip over my standard question about someone smoking. I move forward into a thorough investigation of exactly who is smoking and when and then begin looking for a remedy. The smoky smell puts me on alert for other things about the family that will put the baby at risk.

One of the most troubling odors I have encountered is alcohol on the breath of a father who had driven his child to the office for a well-child visit. This meant confronting him and then finding his wife so that she could become the designated driver. As uncomfortable as that encounter was, it did lead to a first stab at family counseling and a trip to Alcoholics Anonymous.

My nose reminds me that I live and practice in a community with socioeconomic diversity. Although they usually try to disguise their occupational odors, sometimes people just don't have enough time to do a thorough decontamination. The cattle and dairy farmers arrive with a hint of eau de barnyard, the woodcutters with a mixture of fresh sawdust and chainsaw oil. Fathers who have had to prime balky carburetors by hand to get the old family pickup truck going show up smelling of gasoline and axle grease. The lobstermen and sardine packers may arrive smelling of fish. But fortunately, we aren't too fashion conscious here in Maine, and I must rarely endure the overdoses of designer perfume that those of you in big cities encounter.

Although some of these odors are unpleasant even in small doses, the smell that bothers me the most is that of a well-cooked meal on a family when my lunch is a distant memory and dinner is still a waiting room full of patients away.

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