As a physician, I have a rough and ready rule of thumb for when to send my surgical patients home: if you can walk and you can eat, then you are probably better off at home (assuming no complications). Hospitals are dangerous places, more dangerous than, say, a freeway. Like the airlines, hospitals try to keep every bed (seat) filled all the time. So when a patient leaves a room, housekeeping comes in and cleans it, but, really, do they get all the nooks and crannies, all the edges and crevices of the bed, the light switches, the nurse call button … it’s hopeless to think my rooms were free of any contaminant from recent or even distant occupants.
But, for most of my stay, it was very clear to me that I needed to be there. At least 2-3 times a day, my trach tube got so plugged up I couldn’t cough it open, and I needed an RN or Respiratory Therapist to come in and “deep suction” my tube. This involved sticking a plastic tube into the hole and going in until I start to gag, then starting to suck the resultant expectorant while the catheter is withdrawn. Some people were more gentle than others, and I was completely at their mercy.
I could barely walk to the elevators, much less down to the first floor and outside, without leaning on my wife and stopping to rest every five minutes or so. I had NO desire to do any care for myself – I was beholden to the various automatic pumps which registered flow rates for food through my nose tube and fluid through my IV. Nurses came by with alarming irregularity to give me medicines, take my vital signs, and query me as to pain level (I faked it and said I had pain, when all I really felt was a little ache from swelling).
By the second week, on my 9th day there, I was freed of the ICU. The urinary catheter was out, and the pulse oximeter and telemetry were no longer needed. With only a trach, an IV, a C-collar, and my hi-calorie feeding via NG tube, I was “well” enough to go to a “Med-Surg” floor. Here, instead of a new set of nurses every 12 hours, I got re-assessed every 8 hours, with the 11-7 night shift insisting on coming in, waking me up, listening to my perfectly functioning heart and lungs, checking my foot pulses, and asking me the same questions I’d just answered at 4 PM. By this time, I was not so out of it that I could handle sleeping at all hours of the day and night. I was beginning to revert to my usual 10:38 PM to 5:15 AM sleep cycle; it’s hard for me, in normal life, to sleep at times other than that schedule (give or take 10-15 minutes on either side!) Besides, with a collar on my neck, needle in my right wrist, a splint on my left wrist, the trach and mist tube at my neck, and the NG hooked to the feeding solution, it was almost impossible to find any position, comfortable or otherwise, to sleep which didn’t compromise the function of one of those external connections.
It was hard for me to tell which problem was my worst, which medical issue was keeping me in the hospital. I desperately wanted to go home, to be free enough to eat, walk, and putter around my own house.
The ENT doc called in a Speech Therapist to do a swallowing analysis. Se brought in a tray of goodies. First I tried downing some cranberry mush, then some even thicker apple mush. It tasted great to me, and I thought I was swallowing it just fine, feeling it go down my throat. I was convinced I could eat that mushy stuff just fine, and tried to coerce my doctor into letting me eat. But despite the ST’s cheery reassurances at my initial swallowing attempts, she was not about to let me try anything other than some ice chips at this time. Instead, they scheduled a swallowing study.
This uses fluoroscopy and barium laced mushy foods of varying thicknesses. The ST and the Radiologist hovered behind the protective glass, as well as aprons of lead (even with high collars to protect their thyroids!) They mumbled things like “There – see it’s leaking down.” “He doesn’t seem to feel it at all; the larynx isn’t even moving.”
Apparently I had “silent aspiration”. While I could swallow, a lot of what I took in went down the wrong hole – and I wasn’t even aware of it. This was devastating to me. Me, who for fifty years has been swimming without ever once drowning! Me, who could keep even the smallest amount of chlorine laced water out of my lungs, was unable to perform the simple act of swallowing without risking death.
The ENT doc tried to explain it all to me. (If this makes no sense to you, you’re not alone). My broken hyoid bone and the pharyngeal swelling were conspiring to prevent the epiglottis from flopping down like a collapsing awning over the larynx. And once something hit the larynx, instead of going down the back way into the esophagus, I was not sensing the intrusion, and food was trickling down my trachea towards my lungs. Risking aspiration pneumonia, a deadly complication. He speculated that possibly my superior laryngeal nerve had been damaged. While function might eventually return, the growth rate for nerves is one millimeter per day; repair might take months. I was in a blue funk the rest of the afternoon, and ten started to practice swallowing with those tiny spiral ice chips, letting them melt, and then trying to force them down the right direction.
If I was going to need tube feeding for weeks, I began to negotiate for switching my NG tube to one directly into my stomach. The weekend doctor, who was very caring – he actually sat at the bedside instead of hovering over me, and took the time to “listen” (I still wasn’t talking yet) to me – nonetheless seemed quite skeptical when I asked to have the switch.
See, there are two different ways to put this tube in. One requires a surgical approach, with an endoscope being threaded via the mouth into the stomach, and an incision made on the left side just below the ribs, to hack into the stomach at the right spot and snake the tube in, all under the direct visualization the scope provides. This method has a relatively high complication rate. It’s called a “PEG” tube (per-cutaneous esophagoscopic gastrostomy, or something like that). It’s what is usually done for people who need long term feeding bypassing the mouth or throat – cancer patients, and the like, many of whom are sick and/or obese to begin with.
The other way is really a snap. A new kind of specialist – an Interventional Radiologist(IR) – finds your stomach after putting dye or air down the NG tube, and then he just sticks a needle thru your skin watching where that needle is going via ultrasound. These guys are slick – they are more surgeon than radiologist, and my total lack of belly fat would make the process a breeze, to say nothing of my general all around good health reducing the risk of problems to just about zero.
Still, it took me from Saturday to Wednesday to get it done, and then I had to wait another 24 hours before I could get the NG tube out. At the same time, my trach was being downsized, and thus I was able to start talking by Tuesday, and had it removed on Thursday. I started walking downstairs and outside, spending close to an hour away from my bed at a time.
All this added up to the Trauma team finally deciding I was “well” enough to go home. While I couldn’t really “eat”, with the G-Tube in place, I could easily feed myself. And as for walking, well, I was ready to roll. By Friday at 1 PM, a full 14 days after I played crash-test dummy with the tailgate of a truck, I was going home. Home with an irritating plastic tube into my stomach, through which I had to pump or drain all my calories. And a nasty plastic collar around my neck. But I knew it was time to go; I was no longer debilitated enough to need the awesome power of the many therapists in the hospital; I would be thrown onto my own resources, sink or swim, and good luck to ya, doc.