EMERGENCY MEDICINE

Bad odor finally gets woman to seek help

JDR. ERIKA KUBE

an came into the emergency department complaining of chest pain. When I walked in the room, I noticed a bad odor. I immediately started asking Jan about her symptoms.

She was vague with all of her answers, and I really wasn't sure what was going on with her. I noticed her husband sitting in the corner with his

head hidden behind the newspaper that he was reading. I was hoping he would help her along, but he didn't look up or speak at all.

I smelled the bad smell again and tried to hide my facial expression. I looked at her head and examined her neck. Then I listened to her heart and lungs. I pushed on her abdomen. I examined her legs. Everything seemed normal so far.

Then I asked to look at the skin on her chest to see whether she had a rash, such as shingles, that could be causing her pain. As I pulled her gown from her chest, the smell became more intense. I initially didn’t see anything abnormal. As I went around to the side of her right breast, I was completely shocked.

There was a large, open wound, and it took me a few seconds to regain my composure. I asked her whether this was causing her pain, and she admitted that it was. I asked her how long the wound had been present, and she said for over a year.

A whole year? I couldn’t believe it. How could she have dealt with this for so long and not been to a doctor to have it checked out? What did her husband think? Surely he must have known something was wrong. And the smell? How could she have tolerated it?

Jan seemed concerned but was also strangely calm. She told me that she had noticed a lump in her breast nearly two years earlier. She was too afraid to get it evaluated. She said it progressively got larger and became an open wound about two months before she came to the emergency department. She had been using a maxi-pad in her bra to help absorb the drainage. The smell had started over the past week, she said, and it was what finally made her come in.

Unfortunately, I was certain that she had breast cancer, and, by the way she was answering questions, I think that she knew that she did, too. When I probed further to determine why she had waited so long, Jan said she didn’t think her family could handle any more bad news.

As it turns out, Jan’s husband had lost his job around the same time that Jan discovered her mass. She was afraid that if she went to the doctor, and they determined that she did have cancer, she wouldn't have health insurance or be able to afford treatment.

After her husband’s job loss, her daughter suffered a miscarriage. Thankfully, her daughter was able to get pregnant again, and although the next pregnancy was stressful because they feared she would miscarry again, she had a healthy baby.

Jan said she enjoyed being a grandma and didn’t want to worry her daughter. Her husband found a new job with good insurance benefits. Things were looking up for her family, but she just kept putting off getting evaluated.

I tried engaging her husband in the conversation, but he just kept his head behind his newspaper. He finally put the paper down when I said Jan needed to be admitted to the hospital. I told her that she needed to have a biopsy of the mass and undergo further evaluation to determine the extent of her cancer.

I expected Jan to cry, but she didn’t. She said she was actually feeling a little relieved because she had finally taken the first step to getting treatment for what she had long feared was cancer.

I don’t always understand what causes my patients to come into the emergency department when they do. We could have offered Jan more medically if we had been able to diagnose her cancer sooner. But I also understand that it was complicated for her to seek medical attention sooner because of all that was going on with her family. It’s strange to say, but I was grateful that she finally came in because of a bad smell.

Dr. Erika Kube is an emergency physician who works for Mid-ohio Emergency Services and Ohiohealth. drerikakubemd@gmail.com