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. 

What I Do: Part I

Since I've recently started a new job and I often get comments and emails asking what I do for a living, I thought I would do a two-part write up about speech therapy and exactly what I do. Part I will be more about speech therapy in general and a brief summary of my grad school experience and Part II will be more about what exactly I do in my specific job.

It would be extremely difficult to put everything there is to know about a speech-language pathologist (SLP) into a blog post; however, I am going to try to sum what we do up into a few paragraphs.  A lot of people think "you help kids with /r/ and kids who stutter" - and yes, that's true, but there's more. A lot more. 

A basic definition: a SLP is someone who evaluates, diagnoses, and treats speech, language, cognitive, and swallowing disorders. We work with newborns, toddlers, elementary age, high school age, young adults, adults, and the elderly on a variety of different types of disorders and/or delays - articulation, phonology, fluency, cognition, language, voice, swallowing, and literacy. We work in daycares, pre-schools, school systems, rehab centers, nursing homes, hospitals, private practices, traveling, and some even participate in telepractice. Our clients could have autism, down's syndrome, MS, cochlear implants, accents, a stroke, aphasia, dysphagia, dysarthria, and several other disorders/conditions.

Moving on - grad school was two years (five semesters) of balancing classwork and clinicals. Not all graduate programs for speech are set up the same way. I know some programs have the students take the classes first and then do all their clinicals, but I love the way ours was set up. We had classes on Tuesdays and Thursdays and clinicals on Monday, Wednesday, and Fridays - we were learning the classwork as we were performing the therapy. During our last semester, in addition to classes and clinicals, we also had our master's project - and the majority of us also took the praxis. So definitely a stressful time, but rewarding to complete everything! 

My first two semesters my clinicals were in pre-schools. I traveled to different pre-schools and mostly performed articulation and language therapy - although, I did have to do a couple evaluations. My third semester (over the summer) was in a hospital. The hospital had a rehab center beside the facility, so I was also able to get a few hours there - which was nice for the experience. In the hospital the majority of the patients seen is for dysphagia - which is the medical term for a swallowing disorder. More about this in Part II! My fourth semester was at a K-5 elementary school which also had a More at Four program, so I was able to get lots of screening and evaluation experience with pre-schoolers. In the elementary school my caseload was mostly articulation therapy, but I definitely had some language and literacy in the mix. My final placement was in an after-school literacy program that a group of us (plus our supervisor) put together. We basically spent the first couple of weeks testing and determining a baseline for the children - so we could put them in groups determined by skill level. Then we spent several weeks coming after school for about an hour and a half following an evidence-based literacy program - teaching them about letters, sounds, combining the two, and new vocabulary words. At the end of the semester we re-evaluated them and they all showed improvement. It was fabulous - definitely a favorite clinical of mine!

In addition to classes and clinicals, I was also an officer for our local chapter of NSSLHA - which is our national organization for speech-language and hearing. My specific title was Historian/Creative Director, but we were all so close and worked so well together that with most events we all pitched in, shared roles, and just worked to get the job done. To name a few, we participated in Operation Christmas Child, local food drives, local festivals, and we put together an inaugural 5K run/walk for Full Spectrum Farms - a fabulous organization our program worked closely with. Here we are! Such a fabulous group - love them! 

So this is a very quick and dry explanation of my grad school experience - there's so much more to share, but I could end up writing for days. If you want to know more about something specifically, or have a question about anything - ask in the comments - or email! After I complete Part II, I'll write up a Q&A for any questions you all might have. So ask away!