Dying: Sounds and Smells

In the Miracle Center intensive care unit, the chief resident discusses the readings taken from a Swan-Ganz catheter that sits inside the heart of a Mr. Tobias. The students and interns are wrapped up in the medical issues of his heart attack, in the urgency of a situation that has lost all its urgency for me. The debate goes from a pacemaker to digitalis. While they debate, I picture Sir William Withering, the discoverer of digitalis, holding foxglove in his hand and wondering if it really cured dropsy, as his patients claimed, or merely created that illusion. Secretly, I believe it was the word, foxglove. Listen to it: fox and glove. What incongruous images: how impossible not to smile. I would like to think that it was the sight of those long tubular flowers spilling from his fingers, purplish and vibrant, that made him pursue his investigations.

We are nearing Luther Hines's room. I know. I can smell it. There are so many distinct smells in medicine: the mousy, ammoniacal odor of liver failure, an odor always linked to yellow eyes and a swollen belly; the urinelike odor of renal failure; the fetid odor of a lung abscess; the acetonelike odor of diabetic coma; the rotten-apple odor of gas gangrene; the freshly-baked-bread odor of typhoid fever. But this new smell that is not yet in the textbooks tops them all. Now, the redolence is so strong my nose wrinkles. I ask the students and residents if they smell it? They look at me strangely; one student, an obliging fellow, says, "I think I do."

It is the smell of unremittent fever in AIDS, fever that has gone on not for days or weeks, but for months. It is the scent of skin that has lost its luster and flakes at the touch, creating a dust storm in the ray of sunshine that straddles the bed. It is a scent of hair that has turned translucent, become sparse and no longer hides the scalp, of hair that is matted by sweat, and molded by a pillow...

On his deathbed now, Luther looks worse even than he did when he was up and about. His mother and father are in the room, pressed into one corner by our entry. Luther's lips are cracked and his mouth is filled with white patches. He inhales air noisly and erratically into his windpipe, dispensing with the niceties of nostrils, lips or cheeks because of his air hunger. Wisely, many weeks ago, he vetoed a ventilator --- it surprised me. I thought out of spite he would say "do everything." But even he had no stomach for that; he had been ill a for a long spell in California.

A wavy frost line has formed over his forehead. Like the remnants left by waves on a beach, the salt from his sweat has condensed on his brow. His skin is hot to the touch.

I call out loudly, "Luther!" There is a barely perceptible raising of his eyebrows, a turn of his head, but the eyelids remain half-set. Underneath the lids, the eyeballs are roving, as if scanning the ceiling, searching for someone. This is "coma vigil," the same as Otis Jackson [a previous AIDS patient] displayed before he died. In the preantibiotic era, when nothing could be done for most fevers, physicians painstakingly described the features of the "typhoid state," a terminal event. Luther has not only the "coma vigil" of the typhoid state, but also "muttering delirium" and "floccillation" --- picking at the bedclothes. Since there is little I can do for Luther, I too point out to the residents the features of the typhoid state. They are not greatly appreciative: numbers from a Swan-Ganz cardiac catheter have more allure for them.

The medical students and residents are quiet, hovering around the bed, uncomfortable because death is staring at them. I am uncomfortable too, and I am angry all the time now. This is what I think when I lie awake at night: I want to start all over again. I don't ever want to leave AIDS work --- what else will I do? The battle of white blood cell and antibody and T cell with virus or bacteria continues to fascinate me. I want to start in a new community with a new set of names and faces.

When I began in Johnson City I was ambitious, fascinated by the virus and by my patients. I maintained no distance, denying to myself that this was a fatal illness. The future, when all my patients were dying, seemed remote and vague. I convinced myself that I could handle that. But I simply did not understand how devastating it would be to watch. All the stories that I have painfully collected have come to haunt me with their tragic endings, as if I am the author and must take full responsibility. In a new place I can begin again from a wiser and more careful vantage.

The students and residents are waiting on me. I have been lost in thought. What am I supposed to do here, at this bedside? I have, for which I will always be thankful, the ritual of the examination. I put my hand on Luther: his pulse is difficult to detect, a faint thread under my finger. His belly is scooped out and hollow. I can feel the liver, and on the left side the spleen; both are much enlarged. As I press down on his flanks, I feel his kidneys slip under my palm with each breath he takes, pushed down by the descent of his diaphragm.

I palpate Luther's neck, armpits and groin for lymph nodes. I flash my penlight into his pupils, nose, mouth. I pull out my stethoscope and listen over his neck, heart, chest, belly, and femoral arteries. I unsheathe my tendon hammer and tap his biceps, then his triceps. I move down to elicit the knee and ankle jerks. Then I flip the hammer over and use its pointed end to scratch softly at the soles of his feet, noting the brisk flexion of his toes and the extension of his big toe.

I have saved percussion for last.

I percuss his chest, and the sound of his right lung is disturbing. Only at the very top, near his collarbone, do I hear the thoom of resonance. Below that, from above his nipple to his belly, it is dull --- the sound is indistinguishable from the thunk of the liver. The lung has been transformed from a spongy, light, pliant organ to a solidifying, consolidating mass. The sounds of my percussion on his body fill the room. Thoom, thunk, thunk, thunk, tup, tup, tup. I glance at his parents. They listen to the sound of their son as if mesmerized. Once more: thoom, thunk, thunk, tup, tup --- even Luther seems to pause in his delirious muttering, his flocculation, to listen to the music of his body, to relax, to smile.

My tools --- the hammer, the flashlight, the stethoscope --- are scattered on his bed. As I pick them up one by one, I realize that all I had to offer Luther was the ritual of the examination, this dance of a Western shaman. Now the dance is over, and the beeps and blips of monitors register again, as does the bored voice of an operator on the overhead speaker summoning someone stat.

We exit the room and in the halfway our little group is subdued. We have six more patients in the intensive care unit to see. We move on resolutely, wheeling the silver chart rack in front of us. My heart is heayy. I am already thinking of nightfall, of the comfort of my bed, my body.