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July 2, 2003

The Scent of a Diagnosis

JAMA. 2003;290(1):117. doi:10.1001/jama.290.1.117

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 woman.

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 register.

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.