Abstract
A variety of physical examiners are stumped. The differential diagnosis is carefully discussed but no clear answer emerges. Neurology is perplexed, and psychiatry treats, hoping for a good clinical response. Multiple other consultants join the chorus of uncertainty. The possible diagnosis of chronic depression gives sway to even the thought of electroconvulsive therapy.
The swallowing evaluation however, is clear. She cannot safely swallow. Walking around the hall, she reaches out to shake my hand but will not even follow simple verbal commands carefully translated into her language.
After days go by, and a temporary feeding tube, a repeat swallowing assessment confirms our clinical suspicion. She still cannot safely swallow. Ethics grants permission for a permanent feeding tube. A PEG tube is placed.
Aspiration pneumonia soon ensues but fortunately is easily treated.
Her biochemical profile is stable, feedings continue, and other medical issues are addressed and stabilized.
We have performed well medically, but problems beyond our power loom large.
We are ready to discharge, but to where?
She lives with a friend who is willing to help with her care, but cannot commit to 24-hour-a-day care. Her church friends initially rally and gather but are not willing to take on the burden of her total care. An exhaustive search for family is to no avail.
Because she is international and has no legal status, funding her long-term care from government programs is not an option.
Our hospital offers to pay for a nursing home. No takers.
We contemplate repatriation. She has not been to her home country in twenty years. Should we?
We are “it” in a game of “hospital tag.” Her previous hospital had discharged her, but now she is in our institution, so we are responsible for her care, delivering and paying for it. Ethically we have to arrange and pay for her outpatient care.
I am not going to tell you what we did, but since she is mute, I am screaming for her.