Susan M. Beck, MD
Banner Health Systems, Fort Collins, Colorado, United States
Photography by reb
Smell is the sense below the surface; tangled like seaweed, moving in currents, unfurling in the depth of the open ocean.
"Why does poverty smell like laundry detergent?"
I never expected an answer. The long and tangled history of the question began in Baskerville, North Carolina, when I was a medical student. Maybe I remember more about this time because every patient was difficult. In the Roan Mountains, on the border of North Carolina and Tennessee, every patient was also poor.
My attending physician was tired. He had been in practice for well over twenty-five years. He attended deliveries, took care of children and adults. He rounded in the local hospital every morning and took care of patients in the emergency room at night. His clinic hours were Monday through Friday, eight in the morning until six at night. He treated the chronic and episodic illnesses of his patients, which numbered well over five thousand. He was busy. Maybe this was why he let me fly solo in the clinic, because it was the place where I could do the least amount of harm and the greatest amount of good. I hoped it was because he trusted me. But assuming he trusted me made everything that much harder.
I was dismayed and ashamed when I could not hear my patient's heart sounds. He was alive and breathing, which made a pretty good argument that he had a beating heart. He sat in his wheelchair. My eyes fixed on the cracked brown vinyl. The cloth backing had separated from the plastic facing, threads of the fabric wrapped around one another, unfurling in the currents of use. Brown duct tape softened the sharp edges of the seat. The hard plastic armrests were clean, with a layer of furred plastic from so much scrubbing.
His arms, twisted in muscular defeat, rested inside the confines of his chair. My hand traveled over the sharp edges of his ribs that arched, positioned by the attachments to his kyphotic spine. My fingertips grazed his white T-shirt, aware of how tautly his skin stretched over his rib cage.
His heart was singing in the middle of the cage. I was listening through the bars. I kept moving my head closer, unconsciously moving my ears closer, since my stethoscope, shiny and new, was failing me, or so I thought. That is when I smelled the laundry detergent: a sharp scent of pine needles with the balm of lanolin.
I tried to find the scent for months, trying brands of laundry detergent in non-economy size boxes. I ticked off brand name after brand name; maybe that was my mistake, searching for a brand, when I should have been searching for an economy size knock-off. I never found the scent again.
I searched for the sounds of a beating heart. He was patient beyond his years. Probably, more than one medical student searched in vain. His parents' downcast gazes informed me that they were used to waiting. They did not expect more. Their penance was my training. I would come to understand how the poor are paired with the inexperienced in the making of doctors.
I had a momentary feeling that I was trying to listen with a stethoscope to heart sounds in a wooden barn, and I was listening through weathered boards from the outside.
I recognized the barn. I had read my poems on the inside of this barn as an undergraduate when I was writing my thesis. I thought I would be able to hear my own words better if I recited them into emptiness. The barn was listing on its foundations, with a hole in the roof. It was not silent: pigeons cooed and flapped, and there was the occasional sound of farm equipment grinding down the rural Vermont road. There were the sounds of my own footsteps on the old rotting straw and the sounds of my own breath, my own words. This was where I discovered the solemnity of confession. Where my words flew into the loft and returned changed, hardened and alive.
He took a deep breath, out of boredom, or impatience, or both, and I finally heard the ordered repetitions: first heart sound, second heart sound. No extra sounds. A twenty-year-old heart: regular rate, reassuring rhythm. Normal.
My face burned with shame for the fifteen-minute display of my amateur examination skills. My cheeks were still flushed when I came out of the exam room. The clinical nurse who was put in charge of the care and feeding of new medical students tried to restore my lost confidence by preparing me for the next patient. She gently handed me the chart.
"Her brother died three weeks ago."
I did not understand what this had to do with the next patient's chief complaint. I was seeing her for "chest pain."
I was still angry with myself for taking so long to find a heartbeat that was probably there the whole time. I stood outside the closed door, running through the differential of chest pain in a twenty-year-old woman. The list was short, and I was wondering why I had been given this patient ... because what if I couldn't find her heart sounds for some strange reason? What if she really had a problem and I missed it?
With little prompting she went right in to her story. Her words were pressured; she barely took a breath between them. I sighed, but she did not notice.
The pain started after Charlie died. It wrapped around her chest. She had raised him. When she was seven and Charlie was two, their mother had died, so she had raised him. He had been in a car accident. She stayed with him in the hospital, watching the monitors. She knew. Numbers too high, too low. She knew because she watched the nurse's faces. He looked like a monster. She paused and touched her hair, which was the color of straw.
"He was so handsome."
Tears spilled down her cheeks.
She stayed in his closet at night, where she could smell his clothes. She felt close to him, then.
"I don't feel anything at his grave. Nothing. The preacher told me he was meant to die, but I don't understand none of it. People tell me he was evil, and that's why he died. He used to sleep with me at night sometimes."
"Me, a grown woman and him a grown man, almost sixteen, but I loved him like he was my child."
Her face was red; her eyes were on the floor. I asked her what his clothes smelled like.
Her head snapped up, and she looked bewildered, then she smiled.
"Like pine trees and cigarette smoke and something that is only his."
Thankful for the break from studying, I would watch the center of the laundry briefly held in suspension behind the submarine-like glass window. This is the place I stopped, soothed by the repetition. Any second the clothes would drop: floppy scarecrows, gymnastic underwear with elastic bands, and towels with amorphous complexity. I listened to the mechanical hum of the machines and wondered if her brother's clothes smelled the same as my patient's T-shirt. Would the scent of pine and lanolin, without cigarette smoke, have made her remember? Or only "something all his own"?
On the last day of the rotation, I did nursing home rounds with my attending. His white hair was thinning and his pink scalp paled beneath each bank of fluorescent lights. We turned from the hallway into a patient's room, and he sang out in his gentle Carolina drawl:
"Good morning, Miss Phoebe!"
She was withered and abandoned by her family. Occupying this bed at the request of the state.
He examined her quietly and efficiently, moving through the exam like a series of meditations. I noted when he would pause to inhale and exhale. At some point, he remembered I was standing in the doorframe and felt that he should teach me something that was not in a book.
He cradled her foot in his hand and showed me the sole.
"In fall people shed the skin on the bottom of their feet like snakes."
I nodded my head obediently, not really believing him, but appreciative of the kindness. I thought he had reached that point in his career when the accumulation of knowledge is gradually replaced by empiric wisdom.
Twenty years have gone by since that day. I no longer plead amateur status, but certainty is elusive. I listen to the music of the human heart as if it is coming from a conch shell waiting for a human ear to release it. Is this confession or prayer? Is the pain of memory just a collection of molecules touching receptors?
When I asked my co-worker why poverty smells like laundry detergent she said: "Because the rinse cycle is too short to get out all the detergent out of the fabric in Laundromats."
I asked because I owed a debt of gratitude to my teachers, both patients and colleagues. I asked because I was now tired, nearing the end of my career where the accumulation of knowledge was supplanted by empiric wisdom. I already see the trajectory of my memories passing into myth, like shedding skin in the fall.
I wish for a barn, long since torn down, to send the words into silence and have them return as more answers than questions.
SUSAN M. BECK, MD, is a writer and physician. She lives in Colorado with her son. She attended Bennington College as an undergraduate and the University of North Carolina at Chapel Hill for medical school. For internship and residency she went to the Fort Collins Family Medicine residency program. She practices family medicine and urgent care.