Here comes the much awaited summer after the coldest winter in decades. It didn’t warm up in earnest until June. New medical students, residents and fellows were eagerly waiting for the start of patient rounds. Hospital assignments in July need especial attention until the interns and residents settle in. Some had travelled across oceans and were completely new to the culture. Others had just left their loved one for the first time and home sick in a new city.
The anxiety of rounding with attending physicians makes everyone nervous about a trivial medical question that can be thrown at you that can take you off guard. So when the attending physician walked in at 9 am everyone was ready to round having made final touches to either vital signs or physical exam findings or assessment and plans about their patients.
The introduction was brief: a medical student from Kansas, an intern from Detroit, a resident from Peru, a visiting scholar from Egypt; a melting pot, like what America is any way.
The attending physician briefly described expectations for the month. The hospital’s teaching rotations are on monthly basis. Trainees get feedbacks and evaluations at the end of each month. Shortly after that they pulled chairs and sat for brief chart rounds before actually going to the patients’ rooms.
It wasn’t long before everyone started to feel unease, some even uncomfortable. The questions were appropriate to the level of training and they picked them up one by one with correct answers. What a smart group it was. They were not interrupted by pages from the nurses either. The attending physician was also nervous.
There was a strong and non –verbal signal, foot odour!
The human scent is genetically controlled but there are several factors that can influence it such as dietary and medicinal intake and use of fragrance products. When there is over secretion of sweat or what is termed as hyper-hyperhidrosis, the excessive water leads to bacterial overgrowth creating malodor which can create embarrassment and diminishes self-confident. Some individuals may not smell that particular odor (anosmia) and may not recognize it until alerted. Sweat on the other hand is very important to regulate body temperature enabling us to live in different climates. Sweat gland secretions are odorless but also secrete malodor precursors such as proteins, lipids, volatile short-chain fatty acids which when metabolized by bacterial can give rise to malodour. Emotional stimuli can also lead to sweat secretions particularly from palms and soles where there is high concentration of sweat glands. Foot odour is mainly due to short chain fatty acids. Isovaleric acid is a common foot odourant. It is catabolized from glycerol and lactic acid by bacterias which are part of the normal skin flora such as Propionibacteria, Staphylococcus, and Corynebacteria. Bacterial prefer humid environment. Topical anti-perspirants to diminish sweat which often contain metallic salts are often first lines of treatment. Local every day remedies such as baking soda or anti-microbial agents and odour absorbers can also be employed as treatment.
The round continued in to bedsides. The odour got worse as the day went by. Most managed distracted by the teaching and the work load ahead of them.
No one was sure where it was coming from until of course he left…
That physician was me.
Int J Cosmet Sci. 2011 Aug;33(4):298-311.