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*drum roll* Modified barium swallow (MBS) time!

Where I am working, an MBS is scheduled to take about 2 hours time.  Now, I have no other basis for comparison, but I suspect this is on the luxurious side of things.  I’ll talk about what we do, though, in that 2 hour time.

If we have never seen or met the patient before, we meet the patient first and hear about their complaints with swallowing and a bit of a medical history.  While we’re there, we also make sure they know why they are there and what an MBS entails, and do an oral mech exam.  Then we all make our way down to radiology.

If we’ve already seen the patient, our MBS study starts here.  In any case, the client signs in while we go set up in the back.  We grab all the barium-filled food:  thin liquid barium, nectar-thick barium, honey-thick barium, pudding barium, and a package of Lorna Doone cookies that we put the barium pudding on.  Yum, right?  (That reminds me, I really need to try this at some point, just so I know what my patients are eating.)  Then we put on our lead clothes to protect from the radiation.  There’s both a skirt that Velcros around the waist and a vest with an extra piece to cover your neck.  It has taken me a hilariously long time to learn how to put all the pieces on correctly.  Yep, that’s right, every time we have an MBS everyone gets to stand around and watch the new intern struggle to put on protective wear.

They bring the patient in.  Normally, the patient has to stand because the x-ray machine is very narrow.  However, for patients with limited mobility there is a special chair that is narrow enough to fit in the machine.  So far, all the patients I have seen have needed the modified chair.  In any case, once the patient is in the machine, the radiologist comes in.  We all stand around the monitor (the patient can watch to) and we point out some landmarks for the patient so that can have an idea of what is going on during the study.  We follow Jeri Logemann’s protocol of first starting with thin liquid, then pudding, and then doing the other thickened liquids and barium cookie as necessary.  The order of presentation is  3 ml (1/2 teaspoon), 5 ml (full teaspoon), and then a full sip or bite as needed.  If the patient can feed themselves, let them do so, but you might want to give them the presentation sizes yourself (e.g. the half teaspoon), especially if you think they are aspirating.

You present the bolus and then watch the screen for the swallow.  If the patient is cognitively capable of following directions, it’s helpful to tell the patient to hold the bolus in their mouth and then swallow when you say.  To reduce radiation, the radiologist will only turn on the x-ray during the swallow.  The radiologist’s position is usually such that they can’t see when the patient has the bolus and is swallowing, so saying swallow to the patient and/or nodding to the radiologist to let them know when the patient has swallowed is helpful.

As with the bedside swallow exam, if you observe the patient having difficulties when swallowing, you can try out certain compensatory strategies as well as thickened liquids, such as tucking the chin, multiple swallows, and so on.  It is always, always, always better if you can give the patient strategies rather than thickened liquids and/or an altered diet consistency.  I mean, think about how you would prefer to have your food?  I think you’d rather tuck your chin for every swallow than be stuck on a puree or thicken-liquid diet.

Anyway, that’s basically the MBS.  Here, the swallow study is recorded on DVD and we watch it afterwards with the radiologist and talk about what we saw.  That, based on various reports, is not the norm in most hospitals (probably 99%).  In most hospitals, you have to make the diagnosis on the spot about what’s being aspirated, if the hyoid bone and larynx aren’t lifting up and forward, if the epiglottis is inverting, and so forth.  I’m trying really hard to watch everything while I’m doing the study and not rely on the review of the video afterwards since I know that luxury will not be available in almost any job I may have in the future.  It’s really hard.  I love doing the MBS, but trying to catch every part of a swallow that takes approximately 2 seconds takes some serious practice.

Anyway, after that, we go back to our offices and discuss the results with a patient.  We happen to have a handy model that we can use to demonstrate what we saw.  If you don’t have a model and/or picture handy, you should.  One of the requirements for my dysphagia class was being able to draw all the structures important in a swallow and I’m glad I did.  If I’m ever in a pinch, I can always draw a model to use for explanation.  You explain if there need to be any diet modifications and what those are.  And, of course, ask if they have any questions.

Whew!  Is it any wonder they schedule a full 2 hours for it here?  We’ve never gone the full 2 hours, but it has usually take about 90 minutes each time.  Maybe that will get faster now that I have the lead clothing down.

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I am side-tracking from my post about modified barium swallows to that of cognitive-linguistic assessment.  I love this stuff (as I’ve said before) and so I’m always interested in what others are doing in both treatment and assessment.

T, one of the SLPs at my hospital, it’s the cognitive-linguistic guru and I got to assist her in one assessment.  I was interested in the program she used for assessment as it was quick and dirty and provided access to many different types of attention, working memory, and executive functions tests.  The program is NeuropsychOnline.  The one I saw was technically the kid version, but I imagine the adult version tests similar areas with, perhaps, a slightly different presentation.

The first test examined response time (processing time) and required clicking a button on the screen right after it turned yellow.  Another test looked at divided attention by having the patient click multiple colored squares that tracked across the screen in different directions that match a colored square in the middle of the screen.  Another tests visual memory by presenting an increasingly longer string of numbers and having the patient type them back.  Auditory memory is also tested by presenting increasingly longer strings of numbers auditorily and having the patient type them back.  Another test I observed was listening to a phone message, and then answering 10 multiple choice questions about it afterward.  There was also a visual (read-only) version of this.

These are all the tests I observed, but that was certainly not all that was available.  I have never seen a computer version of cognitive-linguistic evaluation or treatment and I’m glad to know it’s out there.  As of now, I still feel I would use different parts of paper tests to get the information I wanted (e.g. Weschler Memory Scale-III; Rivermead Behavioral Test; Test of Everyday Attention, Animal Naming from the BDAE, etc.).  However, I would likely consider the computer option for younger clients, more likely to be familiar with computers, and with whom I really wanted to screen a full range of memory, attention, and executive functions in a limited amount of time.  It would also be a useful resource for a client who wanted to practice some attention and memory drills (and maybe even try out strategies!) at home.  It does cost money, but $24 / month isn’t too bad if the patient can afford it.

It has been really rainy where I am this past week, but tomorrow promises SUN and so I’m very excited about it.  The hospital I am at has the giant, gorgeous windows that allows at lot of sun, so I will be able to see it tomorrow despite actually being at work.

So, I continue to enjoy things immensely.  There’s still been a low number of new consults, so it has been kind of slow.  I am watching my hours like a hawk and trying not to have a panic attack over it.  (I still have 8 weeks left.)  (…But when I say that, it doesn’t sound like a lot.)

Today, I actually got assist in a cognitive-linguistic eval for a new consult, which was really nice.  I love the language and cognition stuff.  (My CI loves swallowing, which is awesome because I think you learn more from people who are passionate about their subject.  So I’m learning to be likewise awesome at swallow evals.)  Anyway, I got to help T with a cognitive-linguistic eval which was really cool.  All the cognitive-linguistic stuff goes to T because none of the other SLPs are interested in it  (CrazyIknowright?).  I’m excited I’ll get to follow her around when CI isn’t here.  (Or maybe even when she has a super-awesome cognitive-linguistic eval to do like today!)  T uses an interesting computer program for some of her eval.  I like it, because it’s a lot quicker than a lot of the cognitive stuff out there.  Although, in a hospital setting, you’d just have to pick and choose subtests anyway.  There’s hardly a test you would have time to give in its entirety.  But, as I said, it’s quick and dirty, and you can jump around to something else if it’s pretty obvious it’s an area they are not having difficulty in, or that they are having a lot of difficulty in.  I’m not recalling the name, but I’ll be sure and get it tomorrow and post it here.

I have also been working on my thesis in the evenings which has cut into my blogging time.  I just turned it in, and because my advisor is awesome, she turned it back around in a couple of days.  Now I have to work on it again, though.  Plus, apparently I completely failed to correct mistakes from the previous draft, so my advisor attached the last set of notes she sent me as well.  How stupid and embarrassing.  Even my idiocy at the extern doesn’t compare (e.g. running into walls, constantly dropping my pen, getting lost on the first floor, etc.).

Anyway, I promised I would write about stuff I’ve been doing.  Modified barium swallows, perhaps.  (Have I mentioned I love those?)  But not this evening…tomorrow!  The thesis/ job hunt awaits.

Whew.  Week one over.  I can tell I’m going to have fun.  I just hope it doesn’t lull me into a false sense of security that will result in massive FAIL.

Anyway, there have been a lot of bedside swallow evaluations this week, so I thought I would talk about those.  A referral (from a doctor) for a bedside swallow can happen for a lot of reasons, including having a stroke, or suspecting aspiration may be causing the patient to have pneumonia.

First, there is a chart review so we can have an idea of what we might expect to see.  (Did they have any cranial nerve damage that might affect the swallow?  Were they intubated and extubated, possibly causing trauma to the vocal folds?)  Then we grab some jello-type stuff (puree), water (think liquid), and graham cracker (regular consistency), plus a spoon and straw and go to the room.  We introduce ourselves and explain why we are there and what we are going to do.  Then we give the oral mech exam.  (Does it need to be said that we wash our hands and glove up?)  We look at tongue symmetry, range of motion (can it move in/out, up/down, side to side), lip symmetry, lip seal (blow out your cheeks), lip range of motion (pucker/smile), and tongue strength.  You can do tongue strength by asking them to stick their tongue inside one of their cheeks and you are going to press on the cheek and they should resist.  Do this for both sides.  Look inside the mouth, check out dentition, tongue, uvula and velum.  Have them say “aaaaah” so you can check out some velar movement (is it symmetrical, timely).  That’s pretty much the oral mech.  You can also check out sensation of lips and tongue if that is a concern by having them close their eyes and using a tongue depressor to lightly brush or touch different parts of the lips and tongue.

Food time.  My CI likes to give puree consistency first, but some SLPs might start with the thin liquid.  So in my case, we start with the puree.  Tell them you are going to be placing your fingers against their throat to feel how things are moving down the throat.  You are feeling for hyolaryngeal elevation and the timeliness of the swallow reflex (is it delayed?  absent?).  If they can feed themselves, tell them to take a bite of puree; if not, then you give them a small spoonful.  After they swallow wait and see if they cough, suggesting their was penetration and/or aspiration.  (This is NOT foolproof way to determine if aspiration has occurred; people can aspirate silently meaning there is not cough triggered when the food goes down into the airway.  If there is any concern that the patient might be a silent aspirator, you should do a modified barium study.)  Ask them a question so you can hear them speak, or just have them say “aaaah” so you can hear the vocal quality.  If it’s clear, food probably didn’t go into the airway.  Check the mouth to make sure there is no food residue (otherwise they are likely having problems with the oral stage of swallowing).  Ask the patient if they feel like all the food is down and/or if they feel like anything got stuck.  Obviously, this is not objective evidence, but it can sometimes give you information about where food might be getting stuck (and that you might want a modified barium study to confirm what is going on).  You can give another bite if the first one seemed to go down okay and repeat all that was mentioned above.  Do the same for first the thin liquids, then the graham cracker.  Really encourage the client to take small bites/sips if they are feeding themselves, and if not give them small bites.  If they are going to aspirate, you don’t want them to aspirate a lot.  Nectar thick and honey thick liquids can also be trialed if the thin liquids did not seem to go down well.

You can also trial some strategies at the bedside.  For example, if they have a lot of residue after eating, try alternating thin liquids after every bite of regular consistency.  That’s basically the bedside swallow evaluation.  After it is over, you can give recommendations for the food consistencies the patient may have and/or recommend a modified barium study and/or recommend the patient be NPO (nothing per oral).

I enjoy the swallowing more than I thought I would.  Probably because it’s like a puzzle, trying to figure out what is wrong and then figuring out what would help this person remain PO (per oral).  Guess that’s reason #354 why I SLP.

It has been ridiculously busy these past few days…but I’m having a blast!  I’m assisting in bedside swallow evaluations, oral mech exams, and even the modified barium swallows.  Where to start?  I guess I’ll start with a general outline of my day, or basically the logistics of what me and my CI do.

General disclaimer:  different SLPs have different caseloads depending on the setting and/or mix of settings they work in.  Your mileage may vary.  This is how my day goes.

The day begins in the Tiny Office of SLP Awesomeness.  My CI does both inpatient and outpatient settings, although most of it is inpatient.  (By inpatient, I’m referring to people who are already admitted to the hospital for some other reason, e.g. stroke.  By outpatient I mean people who come into the clinic via referrals from another doctor.)  If CI has any outpatients scheduled, the appointment times are noted on the schedule.  So far it has not been more than 2 in a day.  Otherwise, my CI seems to have about 5-7 inpatients that he is currently following in the hospital.  We then check and see if there have been any more referrals for evaluations since we last checked yesterday.  Today their were two, but this varies.  We’ve not had a lot of referrals the past couple days, which sucks for me hour-wise, but I realize this means other peoples’ lives are not being affected in a dramatic way.

After that, we work our way through the inpatient list in any order we want to, working around any outpatients we have scheduled.  My CI likes to get the referrals done first thing, which I think is a good idea.  For a lot of these people it’s a matter of whether or not they are going to be eating, and doctors and nurses need to know as soon as possible.  Otherwise the schedule is completely flexible.  I really like this aspect.  It gives one a nice feeling of control over the situation (haha).  In between patients, my CI does the SOAP notes.  This varies from SLP to SLP as I’ve heard in the office.  Some do them immediately (my CI) while others wait until they have a few or more.  This is partly dependent on schedule and is, I think, more easily achieved with inpatient clients.  Since outpatient is all scheduled, you might have one client right after another with hardly a chance to write the SOAP note.  I like writing them right after because everything is still fresh in your mind (and as a student this is incredibly helpful.  I’m just beginning to juggle/remember each of the patients and their issues currently on the caseload.)

The day ends when there are no more patients to see on your caseload.  Pretty cool, huh?  I’m enjoying it so far.  Still having FAIL moments (I mean, I distinctly went against the processing going on in my brain and said flaccid dysarthria was an UPPER motor neuron problem, instead of a LOWER motor neuron problem. Stupid.  I ran into a door.  Gave a bad oral mech.)  Still having WIN moments (I’m remember a lot more from my swallowing and trach classes than I thought.  I have a pager!)  Still trying to be assertive and not so stupidly nervous that I can’t think straight (see also:  my classification of flaccid dysarthria).

That’s all I’ll cover for today, although I feel like I have enough topics for a week’s worth of posts.  Anyone have any preferences about what I write about next?  Bedside swallow evals?  Modified barium studies?  Trialing Passey-Muir speaking valves on trach patients?  Giving a bad oral mech?  (I swear I will nail the next one.  It was like I hadn’t done one before, which I have.)  Feel free to leave a comment if there is one you really want to hear about next and I’ll write it up in the next few days.

Procrastinating Taking a break from staring at tables and numbers (what was my thesis about again?  Kidding!).  Augh my eyes.

Today, I nearly did not lead my first case conference.  I had participated in a few weeks ago, but this is the first one I led.  I started off on the wrong foot, by arriving at school approximately 10 minutes later than I meant to.  I am normally a very punctual person (by which I mean I am always annoying early to everything) and so this made me feel more stressed out than I might have otherwise.  R and I ran around setting everything up, the teacher arrived, and then…we waited.  In fact, we waited so long that we decided that we wouldn’t be having the case conference and that the paperwork would be sent home.

And then…the parent arrived!  There were now approximately 15 minutes until school started and speech therapy with it, so I gave a rushed version of the individualized education plan (IEP) we had created based on the test results.  Phew!  I mean, it is my (and nearly everyone else’s) inclination to rush through things when you’re nervous, so I was desperately trying to balance getting the hell through it, covering everything, and making sense.  All while trying not to talk too fast.  Overall, I felt it went okay.  There are definitely parts of the IEP I could explain better, and would likely develop pat and standard phrases to use once I had gained enough experience with them.  Overall, R only had to interject a few times to clarify and we completed it before the first group for speech arrived.  And that was the first 40 minutes of my day!

The day did not slow down after that.  I was running evaluations that day instead of speech and the day went alarmingly fast.  Three.  Days. Left.  It’s crazy.  It doesn’t feel like that long ago I was 1) starting my school externship and 2) starting this blog.  Have I mentioned everything has been going very fast?

End of a very odd and disjointed week.  Thanks weather!  We did end up having the district-wide SLP meeting yesterday instead of Tuesday.  There was a lot that was discussed and so I’m going to take some more time writing a post up about that, plus I also think I put an update on the Surprise! I Still Have a Thesis to Complete! work I’ve been doing….  I have been busy.  Today, however, I finally got to start my first evaluation.

Basically, R got the referral from a teacher who was concerned about this child’s language abilities.  From the meeting, I gleaned that some of the SLPs got a lot of referrals from teachers, while others got relatively few.  It seemed that some of the SLPs were getting children overreferred to them, so I would strongly stress the SLP educating the teachers in her/his school/s about the kinds of things to look for, and also what does not constitute a referral (i.e. the child scoring C’s and B’s on work who does not appear to otherwise struggle in class.)  In any case, we are giving both speech and language evaluation for this kid.

Friday afternoons,  generally speaking, are set aside for evaluation time.  However, any break that we may have in our schedule does not deter R from going and seeing if she can grab a kid for 20 minutes to give part or all of a test.  Ideal?  Maybe not, but that’s the reality.  It’s either snatching the kids when there are gaps in the SLPs schedule, or canceling sessions for a morning/afternoon/day/whatever and probably having to make up those minutes in order to stay in compliance with kids’ individualized education plans (IEPs).  The choice is up to the SLP, of course, and how s/he makes her/his schedule.  Personally, I prefer the Evaluate-As-You-Have-Time method, and would reserve the canceling for times when I was overrun with evaluations (heaven forbid).

In my case, I managed to get through three tests this afternoon:  The Boehm-3, TACL-3, and SPAT-D. Not too bad, although I totally stopped the TACL after the first subtest and had to be reminded that there was, in fact, more test.  Very smooth.  Next Friday (hopefully), I will give some tests for expressive language and also observe the kid in the classroom.  Not too bad, overall, although, of course, it helps when you have a compliant kid.  I must say, I have never had a particularly recalcitrant kid to test, only one who was slightly resistant until I brought out the stickers.  I shudder to think of testing a difficult child….  I feel very lucky!

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