From dysphagia to euphoria

Patients and physicians can define a ##ldquo;good outcome##rdquo; very differently.

Walking towards the quiet ward and into the patient's dark room early that summer morning, I was pleasantly surprised by what I found. When I asked the patient if she was finally tolerating some intake by mouth, tiny crinkles formed around her sapphire blue eyes.

She hurriedly picked up the paper cup of water at the bedside and swallowed with proud enthusiasm. Her rush to demonstrate to me her newly regained skill reminded me of a young child who wants to share a novel trick with an approving parent. Like an anxious mother anticipating a bad outcome, I took a small step towards her with my fingers slightly outstretched. To prevent further aspiration, I asked her to kindly slow down and take it easy. She tilted her head, smiled and quietly reminded me that until today she had been unable to swallow anything for six months. Her thin face exuded pure and total happiness—she was able to swallow! Couldn't I comprehend that was all that mattered at this treasured and fragile moment?

I never saw her without a genuine smile during her entire hospitalization. Was she aware of how advanced and aggressive her cancer was? Did she blame me for keeping her in the hospital, attempting to abate her fevers but also taking away the remaining tenuous days of her fleeting life? Moments that could be spent enjoying her friends and family were lost as she waited patiently in her cold, stark room.

My first indirect contact with the patient was the previous Monday evening, when I received the standard telephone signout from a hospitalist colleague whose service I would be picking up the next morning. She briefly told me about the patient, whose admission was routine: overnight observation following a procedure.

More specifically, the patient was a 60-year-old woman with advanced adenocarcinoma undergoing chemotherapy who had had an esophageal stent placement that morning. She had elected to have the stent placed because she had lost the ability to swallow her own saliva. The admission seemed straightforward: watch her overnight, then likely discharge in the morning.

When I came in on Tuesday morning to find she had had a temperature of 100.4, I became concerned, as she had been signed out to the nightfloat hospitalist with the standard “NTD” (nothing to do).

She turned out to be a cachectic lady with bright eyes and a contagious smile. Her gentle but raspy laughter revealed her years of smoking. Polite, appreciative, unhurried and with wonderful family and friends, she was an ideal patient. In her evaluation that first morning, she was completely asymptomatic. In fact, she stated that she felt great and was ready to go home. I told her we would watch her until lunch when I would return to re-evaluate her. Then, a few hours later, I received a page from her nurse that her temperature was now 100.8. I started the routine infectious work-up.

She had mild leukocytosis but otherwise her initial work-up was unremarkable. I reviewed her chest X-ray with radiology, which only revealed worsening of her known metastases. She then developed a productive cough and her gastroenterologist who had performed the procedure reported that she had had mild aspiration during the procedure. I returned to radiology the next day to review another chest X-ray and then a chest CT, which had been done to rule out microabscesses, perforation and hematoma formation.

She continued to spike fevers up to 102, now with frequent emesis. First I gave her piperacillin and tazobactam (Zosyn) for a clinical diagnosis of aspiration pneumonia, and then added vancomycin to cover hospital-acquired pneumonia, but five days later she remained febrile. Her metastases on her chest CT had significantly worsened in the past two months since her last CT, but tumor burden could not explain the acute presentation. The gastroenterology team discussed with her that her frail body might not be tolerating the metallic stent, and asked her if she wanted to have it removed. In our attempts to help her, perhaps we were hurting her. Without hesitation, she declined.

Aside from when I have a sore throat, or aspirate when I am multitasking or laugh unexpectedly, I rarely think about swallowing. The simple act lies in an unspecified realm between voluntary and involuntary. But if I could not swallow my own saliva, maybe I too would prefer incessant fevers.

Every morning, I tried to remain optimistic in her presence, although I could only inform her of what she already knew—her fevers were persisting. My worry turned into growing frustration as I watched the long days pass without improvement. Repeated discussions with the patient, her nurses, radiologists and gastroenterologists would not reveal to me the source of her fevers or how I could help her.

Anxiety about whether she would deteriorate right here during this admission and never experience another Oregon rainbow, another holiday, season, or even the simple slow walk down the steps to check the mail, lingered uncomfortably in the back of my mind. Her overnight admission for observation had brought me a perpetual mental rain cloud amidst the bright warm summer days that we passed together in the darkness of her room. The glow of the days could not erase the uncertainty mixed with sadness that held me, but was masked from my patient, whose unbound spirit was almost ethereal.

She showed no fear and never doubted us. She was confident that she would improve and be able to go home soon. Finally, the frequency and intensity of her fevers subsided and I was able to discharge her after a week to finish her remaining course of antibiotics as an outpatient for presumed pneumonia.

Saying goodbye to her and the concerned family who had remained faithfully at her bedside was bittersweet. I was relieved to be able to send her home and felt joy for the small gains she had made. However, I wondered if she would need to be readmitted soon and if so, at what point she would decide it was time. When would the stent not be enough? What other complications might she anticipate?

None of this mattered now, though. For at this cherished moment, she could contentedly swallow. Who among us can say that small feat is not enough?