6.09.2011

What I Do: Part II

As you all know from Part One, I went to school for speech-language pathology. I received an undergraduate degree in communications, with a concentration in disorders, and I went to grad school and received a master's of science in speech language pathology. This post is pretty lengthy, but I figured it would be better to say more than to say less - for this particular post. Anything I don't explain is linked. Enjoy!

I was recently hired as a SLP for the inpatient population at a near-by hospital. The main disorder we treat in the acute setting is dysphagia - which is the medical term for a swallowing disorder; however, we also see patients for aphasia, apraxia, dysarthria, voice, and cognition. Dysphagia typically occurs in the elderly population; however anyone can suffer from the disorder - including premature babies. When we receive a swallowing eval referral from a doctor, our patients usually suffer from one of the following: stroke, Parkinson's disease, muscular dystrophy, cancer of the head and neck, brain injury, heart, brain, or neck surgery, and problems with the esophagus such as acid reflux. So basically anything that causes a patient to have pain or difficulty swallowing is a cause of dysphagia.

Typical signs that a patient is suffering from dysphagia are coughing and/or throat clearing during or after eating or drinking, a "wet" or gurgly sounding voice after eating or drinking, needing extra effort or time to chew or swallow, food/liquid that's leaking or getting stuck in the mouth (pocketing), recurrent pneumonia, weight-loss, dehydration, or malnutrition.

When the referral comes in I do my research on the patient - look at why they were admitted, their past medical history, CT/MRI/MRA of the brain, and what diet they are currently on, if any (sometimes they are NPO - nothing per oral - until we do our evaluation). From this research I can get an initial picture in my mind about how this patient might do when evaluated. Before going into the patient's room I talk with the nurse. Nurses are a great resource to us as they are constantly with the patient and can give great information about how they did eating a meal or taking their pills - this is also true for family members as they can provide an accurate baseline of the patient before being admitted.

The initial eval that I do is called a bedside evaluation. I go in, explain who I am and what I'll be doing, I ask the patient a few questions just to see how oriented they are, and then I do an oral mechanism exam. During an oral mech I typically have them move their tongue around, pucker their lips, and smile - I'm basically looking at coordination and symmetry - I also check out their dentition. I don't want to give an elderly man with no teeth a hard cracker...

At bedside, I give the patient trials of several different food and liquid consistencies. Typically the patient is given ice chips, pureed food (applesauce or pudding), honey-thick liquid, nectar-thick liquid, thin/regular liquid, soft food (nutrigrain bar), and regular food (cracker) - in that order. Now, every patient is different - some ending up trialing all of these and some we have to stop after the pureed. It just depends on the patient. From this evaluation I determine if the patient is safe for oral intake. If so, I decide on a diet that is safest for the patient, call the patient's doctor to discuss the results and my suggested plan, he'll say "ok", and I'll write the order in their chart - at the next meal time the patient is ready to eat! If I feel like a patient isn't safe for food or liquids or I feel like I need to see what's going on during the swallow I will call the doctor, explain what's going on, and ask that a Modified Barium Swallow Study (MBSS) be ordered.

A MBSS is a moving x-ray of the patient's swallow. We give the patient all the foods and liquids mentioned above except with this test we put contrast (barium) on the food and in the liquids so that we can see the food/liquid and exactly where it's going during a swallow. I say "we" because there's always a SLP (me) and a radiologist in the room, giving the test. So you can get better idea of this test, here is a link of a MBSS for a patient who aspirates (watch the second swallow) and one who swallows normally.

Another swallow study performed by SLPs is called a Fiberoptic Endoscopic Evaluation of Swallowing (FEES). This test is different in that it can be performed at bedside and instead of doing a moving x-ray, it's a camera that looks down on the patient's larynx. So basically, in layman's terms, a FEES is done with a flexible fiberoptic endoscope (camera) that is inserted through the nasal cavity and looks down onto the vocal folds, trachea, and esophagus. Here is an example of a FEES - it's a longer video, but it gives you a good idea of how the camera is inserted, what you look at during the test, and the swallowing mechanism itself. At the hospital I am currently working at, we do not have any FEES machines - some hospitals have them, some don't. At the hospital I did my clinicals at they did have them - so I've seen my fair-share of FEES.

After either of these test we have a clearer picture of exactly what's going wrong during the patient's swallow. From there we can determine an appropriate diet and/or if further testing needs to take place - sometimes an esophagram or a neuro consult if we think the dysphagia is secondary to something else that's going on.

Shew! That's a lot! I've spent the majority of this post talking about dysphagia because it's honestly 80-90% of what we see with the inpatient population. I hope I was clear and thorough in my explanations above. Let me know if you have questions - I'd love to answer them or explain anything further. Also, here I am in my scrubs:


*I don't usually wear Wallabees to work, but with my recent foot injury I've had to trade in my Nike's for a looser fit. 

17 comments:

Paigeewa said...

This is so interesting!! I recently graduated with an English degree and I've been contemplating getting a Master's SLP, but the only thing keeping me from doing that is that since I don't have an undergrad in a related field, I'd have to take a bunch more classes and that scares me! Any advice?

Branka said...

I really enjoyed this post, it's so interesting what you do, thanks for sharing!

Brandy said...

Thanks for sharing, Linley! This was really interesting, and you look so cute in your scrubs!

Latoya said...

What an interesting job. It's great for people to learn about the numerous occupations available beyond teaching, law, medicine, etc. On my blog, The Quarter Life Chronicles (http://toya-quarterlifechronicles.blogspot.com) , I talk about career/education. I'm going to link back to these two posts since I think it is helpful.

Annie said...

What a cool post! My little boy has gone into the dysphagia clinic a few times and it took him 3 swallow studies to finally pass without aspirating before we could start the long journey of teaching him how to eat orally. He was on a feeding tube since birth (still has a gtube) and so I think this post is incredibly insightful, even for me having gone through a lot of what you talk about!

He will be starting speech soon and is still in feeding therapy with an amazing therapist! I would love any suggestions though if you have them for feeding, etc. I think you are so amazing to be so educated AND so fashionable! :)

My baby also has been diagnosed with DiGeorge syndrome...how familiar are you with that, if at all?

aejamba(at)hotmail.com

Brooke Ann Dove said...

My mother-in-law and you have the same job. I have seen how happy families become when her patients are successful; it's wonderful. I know people appreciate everything you are doing.

Eclectic Flair said...

Your job sounds so rewarding! And girl, you even make scrubs look cute with those long legs of yours!

Lidi @ Eclectic Flair

Adrienne said...

Hey!

My name is Adrienne and I found your blog recently but I haven't had a chance to comment yet. I just graduated from college with a Communication Disorders major and I am attending grad school for Speech Language Pathology this fall! I love it so far and I have had the opportunity to get some clinical experience during my senior year.

I love your past two explanations about speech therapy and it is interesting to see you are working in the medical area!

Is this your first job out of grad school? Did you feel prepared? I may have some questions for you once school starts :)

Love your scrubs! :)

Adrienne

Natasha said...

Your job actually sounds quite interesting. I always loved science and human biology in school, but never enough to study it in College...instead I chased the fashion dream, which didn't take me too far, got married and popped out a kid..haha
It's funny how clueless I was back in highschool, there are so many jobs out there that I didn't know even existed, maybe had I known a bit more I would have seriously thought about going down the Science road...

Natasha ~ Required2BeInspired

Terri said...

This is fascinating and such important work. My MIL lost her swallowing response after a stroke and through therapy had to be re-taught how to swallow. And yet, this is the very thing that caused her premature death.

kelseywilliams said...

You look adorable in scrubs. :)

JennaStevie said...

This was such an interesting post, it sounds like very important work and much be difficult at the same time too. Very interesting!!
xJennaD

heidi said...

linley, this was so interesting! i'm a social worker and i work with older adults who live in the community and a handful who live in nursing homes, and so i often read/hear about how other disciplines work with my clients and so it's nice to have a bit of background info on what some terms i often see in their charts mean! :) this is so strange, but after i read this post i went and met with an older man and his son told me about him having the swallowing test that you discussed here, and because i had read your post beforehand i knew what he was talking about! anyway, this is really long but i think it's so interesting to read about what other people do, especially from other disciplines that merge with mine so frequently. :) i hope you are enjoying your new job!

Silver Daisy Designs said...

You look adorable even in scrubs!! xo

Lisa D. said...

Sounds like you're loving the new job! Actually, my grandmother recently had a swallowing issue after a bout of thrush in her mouth at the hospital. And thanks to someone like you...she's able to swallow and eat again. =) It's amazing that you're able to help people all day at your job.

I can't believe a knife fell on your foot!! That's so scary. One of my biggest fears in the kitchen actually... It must be my history of working in restaurants, but I actually never use knives without shoes on. Boyfriend thinks that's weird. I hope your foot feels better soon!

Mere said...

Thanks so much for sharing about your new job! (and your grad school) I'm majoring in Linguistics but haven't had any medical classes at all, therefore I'm really debating about whether to go to grad school after I graduate or not! And I graduate in December so I better figure out soon... lol
Congrats on the job, by the way!

~ Kelly Ann ♥ said...

Hi-
I'm new to your blog- I just love it! I'm sending you an email- I have a question --

Kelly