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