Monday, February 27, 2012

What Can Come Out of Your Mouth

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We received a new, quite debilitated patient who was transported four hours from the nearest "big" city. Whitey had been in a top rated nursing facility, the kind that looks like a five-star hotel.

The rehab staff had given up on making progress with him, as evidenced by their therapy notes.

I completed Whitey's chart review and asked myself what I could do to start the process with this guy. What could I do to help him progress steadily so that he could go home with his family?

I went to Whitey's room and immediately heard the sound of a feeding tube at work. The bag of enteral nutrition hung on a pole at his bedside, and I could hear the hum of the machine delivering it to his stomach.

I introduced myself. Whitey opened his eyes. He was "there," but I couldn't understand a word he was trying to tell me. His voice was muffled. His lips were dry.

I immediately realized I needed to check out his mouth. After all,

O.T.s = ADLs
(Occupational therapists = Activities of Daily Living = brushing teeth)

"Let's start with your mouth. I need to moisten your mouth and while we're at it, it would be good brush your teeth. I'll help."

I got the supplies together and put them on his tray.

"Whitey, please open your mouth."

Crooked, brown teeth. Many were missing on the sides, but there were teeth intact in the front and back. I handed him the brush mixed with water and mouthwash. He had been cleared during a swallow study to drink water in the presence of the nurse or the therapist.

He was able only to do a little. My focus shifted from attempting to have him do the whole task to having him hold up his head in neutral. He was so weak that he had difficulty holding his head in neutral and brushing his teeth at the same time. His head kept lilting to the left.

This was an opportunity to strengthen the neck and trunk.

I began flicking at those teeth with the brush. I really should have worn a pair of goggles.

What I had thought were brown teeth were really shiny white teeth covered with a slime of (don't gag) tube feeding and yellow/brown/green phlegm.

I methodically flicked the brush into the crevices of Whitey's teeth until the front teeth were pretty clean. Not bad!


I started on the sides. By this time, I was pulling out solid yellow green clumps. (I know, this is really gross.)

When I got to the inside of the roof of the mouth, I found brownish buildup all around the base of the teeth...

What the heck??

I kept flecking the buildup with the brush, alternating with brushing until a small section peeled away from the tooth. "Oh, my gosh, I thought! I am going to have to reach in and pull it."

That is what I did.

I nearly gagged.
I kept pulling.
He began to gag.
I just kept pulling.

And the roof of Whitey's mouth came a thick, hard, brownish yellow shell of old snot and feeding tube that had not only covered the whole roof of his mouth, but that had been growing down into his throat.

I almost came undone.

No wonder no one could understand him!

The moment that whatever-it-was (a plug??) was pulled out, Whitey's speech could be clearly understood.

In 16 years I have seen nothing like it. I can do blood, wounds and most bodily fluids, but I cannot do phlegm. I felt weak. I can only imagine how he felt!

What do I think about this?

 Even the "best" nursing facilities don't always give the best care. Every person on a G tube needs oral care throughout the day, not just twice a day.

If you have a family member on a tube, check your loved one's mouth.
If you are a caregiver, check your patient's mouth.

You never know what can come out of the mouth...

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