Monthly Melton: Unexpected

There is a peculiar odor emitted in the breath of a patient in diabetic ketoacidosis (DKA), sometimes known as a diabetic coma. Some call it fruity but I think it is more pungent than that. I find the pathophysiology of DKA pretty interesting, but with a 500 word limit I should probably just get to the point. The short version: it’s a condition that happens when a diabetic patient’s glucose gets out of control and remains high for too long.

Among my colleagues in patient care, I find that some cannot detect this odor. I, on the other hand, cannot escape it. Making my charge nurse rounds one night, I was looking for potential admits. While walking the hallway past a cluster of rooms, in one corner I noticed that familiar smell. Not having been notified that any patients in that area might need an inpatient bed I asked out loud, “Who is in DKA?” The nurse in one of the rooms answered, “Oh, that’s my patient. He’s just had too much to drink tonight.” She thought the odor and the patient’s erratic behavior was caused by alcohol. I asked her to take a bedside glucose reading and sure enough, it was too high for the machine to read.

Several weeks later I was working the floor and a child was brought in by EMS who had been found unresponsive at home with no prior medical problems. Under these circumstances a broad range of diagnostic studies would be ordered. The ED doc responsible for this patient witnessed my long distance olfactory detection system in the previous anecdote and asked if I would smell the kid’s breath. No one in the room had detected the DKA smell. When I lifted the oxygen delivering mask, the odor was faint, but there. Before long the patient had an insulin drip, an ICU bed and a diagnosis of new onset type 1 diabetes.

Okay but who cares? Right? Is there a take away? Maybe. I think about the many hours of “sweat equity” invested in learning anatomy, chemistry, and perfecting my technique for IV or Foley catheter inserts. And then one night in the middle of a shift I inadvertently discover I can smell DKA from the hallway. Or I can detect it when other trained caregivers cannot. There’s no skill involved, I was just given a dog-like nose when it comes to sniffing out this diabetes related complication.

Again, I better get to the point. My word allowance is shrinking. The unexpected is what makes the ER such an interesting place to work. Think about your Outlook calendar and how you probably know what to expect for the rest of your day: A meeting here, a call there and then lunch. It mostly goes according to schedule.  Well, there’s no such luck when you work emergencies. Like I said, the ER is an interesting and unpredictable place, and I must say hats off to those who keep clocking in to be someone’s hero on any given day.

Melton out.

 

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