Smell Series: Melena

Melena is the most beautiful name for one of the most disgusting things in medicine. It rolls off the tongue with a certain grace, and if you didn't know better you'd think it was the name of your co-worker's daughter. What it really is, is a technical term for what happens to old blood in new poop: the iron in the blood rusts, and turns from bright red to maroon to a tarry black color. This distinction, between black blood and red blood, is pretty important for physicians and helps us judge the challenge we face in caring for patients who come with bleeding from where the sun don't shine. When the blood we see is "Tarry Black" in color, it has three things:

1. A beautiful name

2. An unforgettable appearance

3. A characteristic smell

Additionally, when the patient comes in looking not much better than a steaming pile of shit, it has one more thing: Our undivided attention.

Melena can be a process that has been ongoing for several months or a warning sign of impending disaster. Therefore its presence in a patient is always more important in context than in isolation. Still, patients don't usually walk into rooms with a sample of poop for us to examine, and many don't think it's worth mentioning that they've had this problem for the last several weeks, in these cases, it can be the smell that saves the day.

The smell of melena is one that everyone in the ER knows well. Not just the physicians, but the nurses, techs, and probably even the registration personnel. The reason for this is that blood in the GI tract is cathartic, and tends to cause a pretty significant diarrhea. So the techs and nurses have to clean it up often, and the stench hangs around for the registration personnel to appreciate afterwards. It's an inky smell, calling it "aged blood" would be appropriate. I've heard people describe it as having a "farm animal" quality, which is also accurate. Luckily it smells more blood than poop, but there's still plenty of poop. Here is the score breakdown

Prevalence: 7 Out of 10. Any busy ER will see this almost daily. As mentioned earlier, the process can be prolonged, occurring over weeks and months, or a rapid process that is acutely life-threatening. The people whom the smell clings to can be spotted as "sick" a mile away and usually brought in immediately. Multiple episodes of this tarry black magic make the air heavy with its presence.

Strength: 8 Out of 10. The smell is horrible, but it is hugely beneficial that it lingers the way it does. I don't want to personally witness the bowel movement, but when the patient comes in an hour afterwards and I can smell it before they can tell me their name, I'm happy to be clued into what's going on sooner rather than later.

Affect on Appetite: 8 Out of 10. If you were raised in a barn alongside farm animals, you'll probably be okay. Anyone else will have a reaction. I've seen gagging, crying, anger at being assaulted with the smell, and a look of hopelessness. The smell will hit anyone in the room and beyond. It can take out an entire hallway. It can make nearby patients request a discharge home.

Prognostic Value: 9 out of 10. Truth be told, rectal bleeding is a very common phenomenon, and the most frequent culprits are self-limited and not dangerous. Most patients who look stable, have had minor bleeding, and are capable of following up with a specialist can go home. IF this smell is present, the likelihood of them matching the above description is almost zero. If someone comes in with abdominal pain, regardless of age, and this is what I smell, they have an uphill battle to convince me that they can go home. It is the only redeeming quality of this smell because so many times patients will simply withhold their GI troubles from us.

Final Score: 32/40

Smell Series: Diabetic Ketoacidosis

    Most "diagnostic" smells are such that they are obvious to the clinician but largely unknown to the patient. The general public may have heard of some common serious illnesses, but they don't have a smell to match the condition in their mind. The smell of Diabetic Ketoacidosis (DKA) is an exception to this rule in that many of our patients come in stating "I could smell it, so I came before I could feel it". Other times, they have become so sick that they are unable to reason their way to a diagnosis even when the smell is overwhelming. 

    DKA is a serious diagnosis, an almost automatic ICU admission in the vast majority of the cases. Even with treatment, outcomes can be devastating, so any help in getting the diagnosis early and starting treatment as quickly as possible is welcomed. It represents the extreme end of the spectrum for patients who are diabetic. The smell is characteristic, and aside from a few rare imitators, is largely found only in patients who have DKA.

    You may detect this smell as soon as you open the door to a patient's room, or only once you've gotten close enough to examine them. This roughly approximates the severity of their case. It is a musty, sweet odor. It is not a bad smell, per se, but its association with death is well engrained in our minds. The patient's skin exudes this smell, and it pours out of their mouth with every word. It smells a bit like sugar-free, fruit flavored gum or nail polish remover. The diagnostic giveaway in adult patients is that they have a prior history of diabetes, but in children who are presenting with this condition for the first time, that information may not be available. Thus, the smell demands a quick evaluation for the presence of this very serious condition. 

Prevalence: 8 out of 10. Any busy emergency department will see these cases on a daily basis and any pediatric ICU will have multiple cases of this concurrently. These patients are sick and know that outside of a hospital they cannot survive

Strength: 6 out of 10. As mentioned previously, it is variable given the length of time the patient has been in DKA. But it is largely unmistakable and the sicker the patient, the harder it is to ignore. 

Effect on Appetite: 2 out of 10. Of all the smells a human body produces, this is the least noxious. The smell of the ketones in the breath is from the same group of compounds used to make perfumes. This smell is more likely to take your appetite due to your concern for the patient's well-being.

Prognostic Value: 9 out of 10. This smell is a harbinger of death for diabetic patients. The majority of these cases will end in death if untreated, and many will die even if aggressively treated. Even though it has a sickly sweet flavor, the implications of it can be sobering.

Final Score: 25/40

Smell Series: Clostridium Difficile Colitis

    Any good clinician will accept data from the patient in any form they can get. Direct questioning, interviewing the family, and thoughtful observation are as valuable as any lab test. Of course embracing the smells of the room is part of this data set. The smell of Clostridium Difficile Colitis is immediately recognizable, but at the same time out of place. It’s a smell that does not seem organic, its character is different from any other smell produced by the human body. If you’ve read the book Dreamcatcher, it smells the way I imagine the parasitic alien fungus does. It’s a deep, inky smell, that dominates over the other smells in the room. It is not diluted by the smell of sweat or urine that often accompanies chronically ill patients. It carries strong notes of ether and organic chemicals that remind me of my time in the lab as an undergrad student. I’ve heard it described as sweet by other providers, which is not a word I’ve ever used to describe fecal matter, but I understand it. It’s a smell I’ve learned to trust, which is its only redeeming quality. Let’s break down the ratings

    Prevalence: 4 out of 10. This is a weekly smell in my experience. Found more frequently in patients who’ve recently been discharged or have been languishing at a nursing home for just a little too long. 

    Strength: 6 out of 10. When it comes to bad smells, this is perfect. It’s strong, immediately detectable when entering the room, but not clingy. A good hand wash with soap and water and the smell stays basically in the room. It does not stay on your clothes. It lingers in the background of the room after the patient has given a sample like music in a hotel lobby. 

    Effect on appetite: 2 out of 10. This smell, as mentioned previously, does not smell organic. It’s not like any other body fluid and therefore it doesn’t have a strong association with food. Think of its affect on appetite like the affect a bad smelling household cleaner would have on appetite. No long term damage. 

    Prognostic Value: 8 out of 10. If a smell can have a redeeming quality, it is this. I can walk into a room and smell this smell and we have a plan for the patient as I’m introducing myself. You cannot accidentally have this smell, it strongly correlated with the presence of Clostridium Difficile Colitis. It can be a debilitating infection, but embracing this smell can give you a head start in resuscitating these severely ill patients. 

Total Score: 20/40

Smell Series: Intro

     Have you ever wondered what it's like to be a fly on the wall at your local Emergency Department? How it feels to be the center of attention when someone's life is on the line? To be there with a grieving family in their time of need, or to give someone the great news that everything will be alright? Have you ever wondered what an average day in the Emergency Department smells like? Well, this next series of posts will answer one of the above questions.

     The Emergency Department, naturally, is a place that requires you to have a thick skin. You have to be able to adapt to any situation at a moment's notice, and not let stressful encounters influence your decision making for your patients. Most people who have been in the Emergency Department, even as patients, can understand this. You also have to have an amazing tolerance for the horrible smells a human body can produce. This part is not as obvious.

     This post will introduce a series of short posts dedicated to the smells that permeate your local Emergency Department. Each post will give a visceral description of a specific smell, and attempt to rate the smell on a 10 point scale in 4 different categories. The categories are the following:

Prevalence: How common is this smell? A nightly phenomenon or a rare treat?

Strength: Is this a smell you'll be taking home with you after your shift? Does it get in your clothes or ruin a jacket? What do you have to do to protect yourself from this stink? Does it overpower the rest of your senses when you enter a room?

Affect on appetite: Some smells are offensive, but easily forgotten. Some will turn your stomach in a way that will ruin your next breakfast, lunch, and dinner. Some will ruin a specific dish for you.

Prognostic Value: How does this smell correlate with the status of the patient's health? Is it a harbinger for disaster, or not particularly malicious? Is it the result of a potentially fatal process, or just a blatant disregard for personal hygiene?

Look for posts tagged "Smell Series" for the entire lineup.

Up first: Clostridium Difficile Colitis