COMMENTARY

Tales From Geriatric Practice: Hard to Swallow

Mark E. Williams, MD

Disclosures

February 18, 2021

My 87-year-old patient was a former amateur boxer who'd achieved some notoriety in his youth. As an adult, he had spent decades working for the US Foreign Service. He was 6'4", 240 lb, and muscular, but not the least bit obese. He had red hair, freckles, a boyish face, and a warm, avuncular manner. He enjoyed telling stories of international travel to exotic places.

My patient's wife was a very talented artist who drew numerous portraits of their family. They had lost a daughter under suspicious circumstances, and while the death was ruled accidental, the emotional scars were always near the surface.

Most of the wife's portraits were of the daughter who had passed away; the images captured the young woman's natural beauty, sweet smile, and youthful innocence. The couple had another daughter who was a gifted artist as well. She was able to weave her grief into stunning works of art and had several art shows in prestigious museums and high-end art galleries.

A Different, More Gradual Loss

When my patient developed significant dementia, he and his wife moved into a lifecare community. Initially his dementia was manageable, but as it progressed, he became more and more disoriented and disruptive, and required nursing home care.

While my patient lost the ability to verbally communicate, he could engage you with his eyes. If you looked familiar to him, he would chuckle and laugh as if he were recognizing an old friend.

Dinner and a Trip to the ED

Things were stable until one December evening when my patient choked on a piece of pork chop. His esophageal obstruction was below his airway. The staff could not perform the Heimlich maneuver on him because of his extreme restlessness and threatening manner. He was sent to the emergency department (ED) in severe distress. The hope was that a gastroenterologist could use an endoscope to push down the impacted piece of meat.

Despite prior communication with the ED, he was superficially evaluated and kept overnight. He was sent back to the facility in the same state that he left in, with the justification that his code status was "do not resuscitate." The gastroenterologist was not inclined to take any further action.

A Patient Whose Eyes Said, 'Do Something'

I saw my patient shortly after he returned from the ED. His wife told me she was frustrated that no one seemed to listen to her. Nothing had been done except to draw blood and document the obstruction on her husband's chest x-ray.

My patient was in significant distress when I examined him. His eyes had a pleading look that said, "Please do something." He could not pass anything through his esophagus, and he kept coughing and aspirating his oral secretions. Something needed to be done before his complete esophageal obstruction resulted in aspiration pneumonia. But what?

Desperation Leads to Inspiration

Desperate moments like this sometimes spark a moment of clarity. I asked one of the floor nurses to go to the kitchen and find some meat tenderizer. Perhaps we could dissolve the meat. We mixed a slurry of the powder in water and asked the patient to sip it slowly. He seemed to know that we were trying to help. I went back on the floor to see another patient.

Twenty minutes later, the nurse called me to his room. I learned that my patient had let out a tremendous belch and the obstruction had passed. He was now smiling broadly and his breathing was not as labored. He grabbed my hand, shook it, and gave me a bear hug that nearly took my breath away.

A small miracle had just happened.

Upon Reflection...

A subsequent literature review revealed that my insight was not unique. Meat tenderizer has been used for esophageal meat impactions. It is risky because the chemicals in the tenderizer can also dissolve parts of the esophagus and increase the risk for esophageal perforation.

Not long after the choking incident, I received a stunning (museum quality) piece of artwork from my patient's daughter with an inscription of her gratitude. The wife continued to paint, but her subject changed: She began doing portraits of her husband.

And my patient? He went on to live another year without any further episodes of choking or swallowing difficulty.

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