45 or Die

“Please, put my head up!” her mind desperately cried out as she choked and gasped for air. She couldn’t speak because a stroke had taken her voice a few months earlier, so she pleaded with her eyes, wide with fear, to anyone who cared to help.

Nobody did, not even when her body rocked violently as she continued to strangle.

“Why is this happening to me?” But she already knew. 

Her body hadn’t been positioned in a 45-degree angle and her lungs were filling with fluid. 

“Please!” she mouthed again and reached out a shaky hand for someone to give her assistance. Luckily, my mother and I walked in, just as a CNA rushed past us down the hall to attend another patient. We stared in disbelief as she laid there, wheezing and clutching her throat as mucus oozed from her mouth. Horrified, I immediately called 911, but pneumonia soon set in, then six weeks later, death.

Nannie, as she preferred to be called, was my beloved grandmother and she had dysphagia, a medical condition where the muscles of her throat were weak and caused her to aspirate (inhale) food, water, or saliva into her lungs. Because of the stroke, she had difficulty swallowing, so solid foods were pureed (blended or grounded into small pieces) and her water was thickened to a honey-like consistency. Whenever she ate or drank, her head had to be at a 90-degree angle and 45-degrees the reminder of the time. When we entered her room that morning, she was flat on her back.

This all began when my grandmother was sent to a rehabilitation center for abdominal feeding tube therapy. From the start, her head wasn’t properly elevated while the feeding machine was on, and incredulously, it wasn’t put on hold or turned off when she was repositioned or changed. Only her second day at the facility, Nannie aspirated.

How did we know? She had vomit on her nightgown. Other symptoms of dysphagia include: difficulty breathing, a gurgly or weak voice, coughing; discharge from the nose, drooling, weight loss, or burping. In some cases, there are no obvious signs: what is referred to as silent aspiration. In my situation, Nannie exhibited most.

When we reached the ER, the attending physician said she’d definitely aspirated because the X-rays showed a significant amount of fluid inside her lungs. Unfortunately, it came as no surprise, for we’d stressed the importance of keeping her in an upright position at all times only to be ignored. As a reminder, a nurse even posted a sign on the wall directly behind Nannie’s bed.

The administrator had it removed. When we asked why, we were told it was policy. A patient’s medical condition couldn’t be made “public knowledge” due to laws about confidentiality. Understandable; nevertheless, I did see several signs throughout the building.

“Oxygen In Use”

“Hearing/Visually Impaired” 

“In Isolation-Do not enter”

Why would one that merely stated, “Please keep head at 45°”, which was written by the charge nurse under a doctor’s direct order, be any less significant?

It wasn’t. Many elderly patients are unable to speak for themselves, and family members are often unavailable, so it goes without saying that CNA’s (particularly new ones) would undoubtedly appreciate a little reminder that keeps them and, most importantly, the patient out of trouble.

After a heated discussion, the administrator hung it on the closet door (on the inside, mind you), and assured us the staff would know where to find the instructions.

They didn’t. Most of the CNAs unintentionally forgot, so Nannie’s head went down and her lungs filled up.

Ultimately, it wasn’t dysphagia that killed my grandmother, but human negligence. With simple precautions and proper treatment (such as medications, exercises to strengthen the throat muscles, or surgery), dysphagia is manageable and often curable. It’s just a matter of deciding which one will make eating enjoyable again.

In the end, if my grandmother had been treated less like a room number and more like a person, she’d still be making me laugh with her funny wisecracks. (“If it was raining soup, I’d be stuck holding a fork!”)

Nannie may have left this world lying on a bed, but in my heart, I know she sped into heaven riding on her motorcycle. She didn’t swallow her pride, but held her head up high and that’s how I’ll always remember her.