To get a driving license one must take a driving test and also do written test to show that one has enough knowledge of driving and safety and rules and regulations . But we know that just because one got the driving permit does not make him or her safe driver and many a times one accident can ruin the insurance risk and also damage the car and also sometimes life . I am often reminded of this when I see certain patients and I also tend to explain patient on risk of accidents. So this is the story of a patient but it applies to may of today's patients as we are seeing aging population and also certain patients who recover from stroke who in past may not have survived .
I saw this 94 years old patient in my office for congestion and cough . I had known him as husband of one of my patients but he was not my patient . He came with his daughter as he had lost his wife who was my patient in recent past . He had mild high blood pressure and no other major problems and I had known him to be the care giver for his wife who was fragile and sick and never thought of his age . He was having cough for last 6 months and has been treated with antibiotics and cough meds by PCP and he has had 3 courses of antibiotics and he has done little better but he still had cough and congestion and so they decided to come to me .He was not in any distress and his blood pressure was good and his oxygen saturation was on low normal side. He did sound congested and he had what looks like productive cough, but he was not able to cough up easily. He did not have any chest X- ray and so I ordered chest X- ray and also set him to get breathing test . He had no problem swallowing , but I ordered the swallow study . I also gave him some mucous thinning medicine and also ordered nebulizer treatments and also put him on medicines -bronchodilator The reason to do the swallow study was my previous experience . In many elderly patients , -even though they may not have problem swallowing- they have some aspiration- food or liquids going wrong way in wind pipe-trachea and then lungs .
As it happened he had a fall and he went to ER and was admitted . I had also done CT scan and hat had shown some infiltrates - what one might see in pneumonia and I had started him on antibiotics. When he was admitted, by hospitalist, he had another CT scan -within less than a week - waste of heath care money-and it did not add to our information. I did the swallow study and also continued what I had started as oi=ut patient , The swallow study did confirm my suspicion that he had silent aspiration. He did not do that every time and not same with all consistency.. So the speech therapist advised some instruction - some precautions to avoid the aspiration. Over period of next 3 days he got better and oxygen saturation improved and congestion improved and he was ready for discharge .
So he had aspiration pneumonia when I saw him and that got worse when he was admitted and he was discharged on precautions to prevent aspiration. But as i was saying one can drive safely for months ot years , and then one can get in an accident and that may be devastating -economically or insurance or health wise. This is my concern when we talk about aspiration. One may do ok 10 times or 100 times or more , but one day or sometimes even everyday one may have SILENT ASPIRATION and that can cause chemical bronchitis - inflammation, that can lead to cough ,congestion and even pneumonia and if it is bad - sepsis or death. This risk is there. Unfortunately there is no answer to this as we can not be doing feeding tubes in everyone who has this problem . Certainly if one has 3 accidents then the liscence to drive will be suspended. Same way if one has 3 episodes of aspiration pneumonia, then we should consider SUSPENDING eating and do feeding tube .