Thick tires made a crunching sound on the gravel of the drive. An engine
sputtered to a stop and settled into a rapid ticking as it cooled. A car door
slammed and footsteps hurried to the door of the clinic. Then came the sound
of a fist knocking solidly against the oak planks.
Upstairs we were just waking up. The air was still cool and thin wisps
of mist clung to the treetops in the nearby rain forest. Morning was breaking
slowly over southern Belize.
The clinic director hurried upstairs to summon us. A man had carried
in his wife, who had been ill all night and was unconscious. They did not
speak English or Spanish, and we had no translator of their Cetche dialect.
The director told us one thing was certain—the woman was in dire straits.
Drew and I looked at each other reluctantly as if drawing straws. We shrugged
in unison and followed the clinic director down the stairs.
We found the patient lolling outside the clinic's door. The polished
red bench on which she lay had been constructed only months earlier as a waiting
area for patients. Most mornings we found four or five young women scrunched
together on the seat busily nursing their rooting infants as we opened the
heavy doors for the beginning of our office hours. Today the patients had
retreated to under a nearby tree. They looked on wide-eyed at the unconscious
She lay awkwardly on her side, one arm folded underneath her where it
had been trapped as she was set down. Her tongue drooped out of her mouth
and a thin string of saliva drained from her lips. She was motionless. Her
eyes were slightly open and her pupils rolled toward the back of her head.
Her husband crouched by her side cradling her head. He looked anxiously up
at us and asked a question we couldn't understand. But its meaning was clear:
he was begging us to save her.
I leaned in with my stethoscope and Drew began to examine her head.
Our rudimentary diagnostic equipment mocked us; we could tell that she was
critically ill, but we were no closer to finding out why. Her pulse was rapid
and thready, her blood pressure low. She had no outward signs of infection
or trauma. Could she have had a stroke? Meningitis? Was she exsanguinating
from a ruptured aneurysm? We could find no explanation, and she wasn't able
to help us at all. She mounted no response to a sternal rub.
Meanwhile, her husband's questions became more panicked. He clung to
my arm as I examined his wife, trying to talk to me. He gestured toward the
truck in which they had arrived. In the front seat of his ancient, rusting
Toyota pickup sat a row of solemn faces. There were six children in all. Two
infants sat in the laps of their older sisters. They watched our motions with
an uncanny stillness, silently absorbing the scene in front of them. One of
the infants gripped his sister's braid in his small hand. I turned back to
our dying patient.
Our stores in the clinic were woefully limited. A volunteer had recently
brought a small supply of ceftriaxone. Now Drew ran to find it. He called
for our two remaining bags of intravenous fluid, usually reserved for children
who were dehydrated from diarrhea. We both felt our isolation acutely. Here,
30 minutes from the most rudimentary hospital, we were essentially powerless.
We had no way of tapping her spinal fluid, no x-ray machine to examine her
for trauma. We could not perform an electrocardiogram or intubate
her if she stopped breathing. We were very alone with this woman who needed
help. I leaned in to look at her eyes again.
Four years earlier in an emergency department, I had been admitting
a patient when one of the attending physicians came over to me. He put his
hand on my shoulder and swung me around in my chair to face him. "Go into
room 3 and take a deep breath. Never forget what you smell."
I opened my eyes and refocused them on the dying woman. Each deep gasping
breath brought a sickly sweet smell. These were Kussmaul respirations—she
was in diabetic ketoacidotic shock. "Do we have a glucometer?" I shouted to
Drew. With shaking hands I coaxed a drop of blood from her fingertip and watched
the blinking digital screen. "Error," it read. I tried again. The numbers
finally appeared: greater than 500, the highest blood sugar the meter could
We had no insulin, but we could start an intravenous drip. We loaded
the woman into our truck on the thin foam mattress that was our only stretcher
and set off on the bumpy 30-minute ride to the district hospital. This time
the woman moaned as we moved her into the truck, already responding to the
liter of fluid.
I crouched in the rear of the truck at her head, holding the intravenous
bag and watching the green canopy of the jungle flash by our windows. Farmers
leaned on their machetes to watch us pass, smoke drifting lazily behind them
on their burning plots. Through the rear windows, I watched the old Toyota
truck bouncing along, moving in and out of view through the clouds of dust
that we raised. There in the front seat sat the six children, their faces
ghostly through the haze.
Glazer JL. The Scent of a Diagnosis. JAMA. 2003;290(1):117. doi:10.1001/jama.290.1.117