Smell memory is very persistent. We can all perhaps remember the smell of our childhood comfort blanket, our mother’s perfume on the saliva moistened hankie that dabbed our chops, the incense at church.
And for doctors like me, smell memory can even save lives.
A few years ago, I was urgently summoned to the “resus” room in A&E at about 6am. (I refer to ITU doctors as “resus monkeys”.) There, a number of junior medics, nurses and I found a puzzling sight. On the ambulance trolley lay an extremely sick two-year-old-boy. His skin was a peculiar chocolatey-purple colour. He was comatose, gasping for breath, and his heart rate was 200 beats per minute – the maximum. His blood pressure was unrecordable. None of us knew what on earth was going on.
His parents stood in the corner of the room looking terrified, but also a bit sheepish. Then the smell hit me. It was the unmistakeable sickly sweet odour of amyl nitrite. This is a medical drug originally used to treat angina and more recently to treat cyanide poisoning. It also is used as a legal high, known as “poppers”.
The child’s clothing reeked of it and so did his breath. I ordered his clothes to be removed and double-bagged for our own safety, and for his body to be washed clean. Amyl nitrite can be absorbed through the skin as well as by inhalation.
I took a sample of blood from the artery in his groin and sent it off for urgent blood gas analysis. I then gave a paralysing drug and passed a tube into his windpipe and ventilated his lungs with 100% oxygen. He remained comatose and critically ill. We might have been too late.
The blood gas result came back: more than 95 per cent of his red blood cell haemoglobin was poisoned by the amyl nitrite and therefore unable to carry oxygen. His blood was racing around his body but failing to deliver life-giving O2. This child was about to die. There was no time to phone a poisons helpline. What could I do?
Suddenly I remembered an obscure nugget of truth. The boy’s haemoglobin had been oxidised by the amyl nitrite to become met-haemoglobin. The iron ion at the heart of the haemoglobin molecule had been changed from Fe2+ to Fe3+, rendering it unable to carry oxygen. This also changed the colour of the blood from bright red to dun mauve.
The treatment for met-haemoglobin is the opposite of the oxidising agent that caused it: a reducing agent. Quickly, quickly, I racked my brain. What medical drug is a reducing agent? I was stumped.
And then again I remembered: methylene blue. This is a dyestuff with many medical uses but is also a powerful reducing agent able to turn Fe3+ back to Fe2+. I had to get some into this child.
This was the next problem. Where in the hospital could I get hold of this unusual compound at this unearthly hour?
Yet again, my memory saved me, and the child. As a medical student I had witnessed a remarkable operation on a patient with osteomyelitis-infected bone. The operation was to excise all the dead infected bone. Methylene blue was given during the operation and stained all the tissue with a blood supply a vivid green colour. The surgeon simply had to excise all that was not green.
If there was any methylene blue to be had, it would be in the orthopaedics theatres. I raced up there and ransacked the cupboards. Eureka! I found a small stock of it. Drug in hand, I now had to work out the dose. This was a two-year-old-patient weighing maybe 12kg. The drug book I had to hand did not specify the dose per kilogram. Time was now very pressing indeed so I was going to have to guess, hopefully with intelligence.
I slowly injected the dye – diluted in saline – and waited. During this time I had a chance to grill the parents to find out the story. Their little fellow had wandered into their bedroom in the early morn. He opened a bedside table and found in there a little bottle of golden yellow fluid with a bright label. With his two-year-old’s logic he interpreted the label as “Drink Me”, and so he did. It was poppers. He promptly collapsed and his parents called the ambulance, thankfully in time before he died on the spot. I didn’t ask them about why exactly they had a bottle of the stuff. That wasn’t my job.
We moved the boy up to the intensive care unit and I sited all the monitoring lines necessary. The end of the shift was approaching. I went into the handover office to tell my fresh colleagues all about the developments of the previous 24 hours. The consultant was not my favourite. He was a bit of an arrogant perfectionist who had never regarded me highly, and was not shy about telling me this. We had religious differences, too: he was an uber-devout Hindu, and at that time I was a very confused Catholic. We all left the office to tour the bedsides.
The last to be visited was the newly arrived child. We went into his side room. The boy was now clearly awake and trying to pull out his breathing tube. All the clinical measurements were now acceptable. We extubated him and he immediately wanted his parents to hold.
Before I went home, I dropped back in to see the little man. He was at play, and even running around the cubicle. I was very pleased for him and his mum and dad.
I bumped into my least favourite consultant on the way out. Uncustomarily shaking my hand, he beamingly said: “That was a superbly good save. Well done!” I was gobsmacked and went home, to my young family and bed, as if walking on air.
Later, I checked up on methaemoglobinaemia. Levels greater than 70 per cent are usually fatal. I contributed to the resolution of this little guy’s misadventure, for sure. His young age was definitely on his side. I wonder where he is now.
So what saved this patient? My memory.
I learnt the smell of amyl nitrite as a bored casualty officer over 10 years before while perusing the cupboards at the back of the shop. There I found a box labelled “Cyanide Kit”. In it were several ampoules of amyl nitrite. Driven by the curiosity that kills cats, some nurses and I cracked one open and had a sniff of the amber liquid inside. Suddenly we felt the blood run to our face and came over all faint. We staggered as our blood pressure plummeted, as our blood vessels dilated. Fortunately, this was short-lived. Chastised, we survived and recovered to finish our shift, never to take that risk again.
As I said before, smell memory is persistent: I can still summon the smell of a rain-soaked May Day morning at dawn in Oxford. We also remember the smell of our own guilt, fear and despair, and our own debauchment. I guess that at the hour of our death we will all each have condensed and matured our own unique eternal fragrance, like a barrel of some single malt whisky, long aged.
I saw an interesting graph in December that plotted life expectancy (LE) against per capita health expenditure (PCHE). At zero health expenditure, LE was about 40-45 years. This is the LE of people living in primitive tribes in the jungle. You might say this is the natural design life of the human body without a maintenance contract.
Very, very quickly, LE increases as money is supplied to sanitation, vaccination and basic health care. The LE plateaus at about 80 years, equating to a national health expenditure of £3,500. Any extra money buys no more LE. The UK spends about this amount on healthcare. The US and Norway gain no greater value for their vastly greater expenditure on health.
Call me morbid, but I consider all medicine as a branch of terminal, palliative care. Everyone born of a woman is dying even from the moment of their conception. This is the inescapable truth about human life: we’re all dying. If we all simultaneously realised this simple truth, there would be peace on Earth as there would be nothing to kill for: we are all dying anyway.
Dying is a very uncomfortable phenomenon. I cannot speak from personal experience, of course, but I have much third-hand evidence that this is so. There is much fear, breathlessness, pain and other agonies, much like Christ suffered on the Cross. Everyman’s death resembles Christ’s.
And this is where I introduce Our Lady. She was there at her Son’s Crucifixion, at His being put upon the spot. Her Immaculate Heart is attuned to the dying. We ask her to pray for us now and at the hour of our death. The distance between now and then is always an unknown.
Memory is one of the soul’s powers, along with understanding and will. My memories will come with me to my Final Judgment. Things sacramentally forgiven will, in a sense, have been forgotten. God is a good and merciful judge, but he may still wrinkle His nostrils at my malodorous pong when I am presented before Him. My hope is in His infinite Mercy, attested to by Revelation, Scripture and Magisterium.
As is all of our Hope. Amen.
Dr John Morrissey is an NHS consultant specialising in care of the critically ill. He is writing under a pseudonym