Is That What I Think It Is?

Guy came in the other night, older, with MS, very anxious and cachectic but claimed he had been injured since Vietnam, was just fine, let me go home. The story was that he had aspirated a bit of pork chop, coughed it up, and was being evaluated for aspiration.

In acute aspiration pneumonitis a patient should present with respiratory distress if they've really aspirated something caustic like gastric contents; this guy was breathing normally, had emphysematous lungs, but otherwise was OK. So I staffed him, and the doc was all, fine, but where is the pork chop now? Are you sure it's out? Where could it be? Hmmm. Lungs, or, esophagus. So get a chest x-ray, and do a bedside swallow study. If he swallows and has a normal CXR, he can go.

So I go back in the room with a cup of water. "I can drink fine", he says. Takes a drink, 'swallows', then spits it back in the cup. Three times we try. I get new water each time because he doesn't want to drink his own spit. The third time he's all, 'I'm fine', but I can hear the gurgling because the water won't go down. Note to self: ALWAYS check swallowing on an aspiration risk.

But it gets better. We pull up the x-ray and I start going through my system-A for airway and lungfields, B for bones, C for cardiac, D for diaphragm and OH LOOK THERE'S A RAZOR BLADE FLOATING IN SPACE. Actually probably stuck in the GE junction, but still. Not supposed to be there. We get his clothes off and gown him and re-shoot. Still there. Call the scope monkeys (hey, my father-in-law is a GI doc, it's a term of affection).

Meanwhile, the dood's sister arrives and says no he doesn't live at home he lives at the mental health complex (and I slapped my forehead internally for not reading the documents that were on the chart) and WE CAN'T FIND A RAZOR BLADE we had there. I didn't even ask why they had a razor blade. The poor guy ended up getting a consult from surg and going upstairs. He looked so sad. And so earnest when he was saying 'I'm fine'. Poor dood.