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After recovering from the haze of pure JOY that is having two consecutive days off in a row, I remembered I will be getting a new client with a disorder that 1) I have worked with only once before and 2) that I don’t know that much about from the evaluation and treatment section. All I have in my brain are the Facts that I learned about in one of my classes. And I plan to review those because I’ve slept a few hundred times since then.

It’s Better Speech and Hearing Month and I have been trying to reflect on things about what I do in my profession to make things better.  One of the most important components to our field is providing evidence-based practice, which can be a challenge because 1) there isn’t always a lot of information about the most evidence-based approach to treating a particular disorder and 2) there is so much breadth to cover in our field, unless in a job that allows specialty in one or few areas of disorders.

Where do I even begin? I love my job and what I do and I don’t mind spending a little bit of time outside work answering questions I have about evaluation and treatment of disorders, but I must have boundaries and I refuse to spend much of my free time on All the Things SLP. (Even though sometimes my perfectionist side tries to push me into SLP overdrive.)

1) First, I look through my grad school notes.  I read the Facts again. I also skim for names of specific authors and/or studies that I can then search through the ASHA website, or, try to access the articles through the library at work.

2) Search the ASHA journal database. The tricky thing is figuring out what keywords to use. Not to mention I don’t think much of the advanced search function on the ASHA journal database. (It does not allow me to use some of the awesome lit search skills I learned as an undergrad.)

3) If I have any colleagues who are familiar with the disorder, I ask for advice, or specific books, or specific articles to read.

Perfect? Probably not. Especially since I don’t have access to as many journals and academic databases as I did in grad school. But it does let me at least skim the surface of the most recent evidence available.



The SLPing SLP’s (very own, very personal, heavily influenced by her graduate training) Definition of Articulation:

So, looking back at my definition of phonology, that…pretty much covers everything.

Basically, when I think of articulation, I think of a strictly motor or placement problem.  For example, I think of a lisp as an articulation problem. Also, if I child is still having difficulty producing sounds after around the age of five or five in a half (when phonological growth plateaus [see Shriberg & Kwiatkowski, 1994; Shriberg et al., 2994-a, -b]), I begin to see it as pretty much a motor issue.  The child has been mis-pronouncing a sound or sounds for so long that is has become a learned motor pattern.

This does affect my approach to treatment, because then I do treat initial, medial, and final position, and I do teach to sentence and/or conversation level. That’s because I am less changing a cognitive system, and more a (long-suffering) motor pattern.  Much harder to do!

(Where does that leave childhood apraxia of speech? Well, I guess that’s something to write about in the future.)

I think the importance in distinguishing articulation from phonology is how it affects treatment. Since I treat (most) my kids as having a phonology problem (how I define phonology), I only spend time teaching them the initial sound in words. (And yes, there is evidence to show that change occurs across the phonological system, by teaching certain sounds and only in initial word position, e.g., Gierut, 2001; Geirut, 1999.) It’s only when they are older and I see it as an articulation (learned motor pattern) problem, do I spend the time teaching it across positions and practicing it in sentences. Otherwise, I would feel like I’m wasting my own and my patient’s time (and insurance) by teaching all sounds, all positions, and all “levels” of production.

The SLPing SLP’s (very own, very personal, heavily influenced by her graduate training) Definition of Phonology:

As wacky as this week is going, I basically want to say: “Whatever is on those dreadful SuperDuper articulation and phonology cards is exactly what I think phonology is NOT.”

And then go read my book club book.  But then I like to think I take this blog a little more seriously than that.  So.

I agree with the ASHA that a phonological disorder is one where a child exhibits “patterns of sound error.”  However, I do not think of these patterns as the phonological processes that have been discussed and described in some areas of literature (final consonant deletion, fronting, backing, etc.; see Khan, 1982 in Language, Speech, and Hearing Services in Schools for an overview of phonological processes).

A pattern to me is when a child is omitting or substituting a sound or set of sounds consistently. While placement (e.g., backing) might be a noticeable pattern, so might whether or not the child is using manner or voice. I then examine these missing sounds and their features and use this to determine which sound or sounds to target.

Because I view phonology (and most the kids on my caseload with a sound/speech disorder) as a problem with a cognitive representation of the English sound system, rather than a strictly motor one, my approach to treatment is different from it is with articulation. If I have a child between the ages of three and four (maybe up to four and a half) with a moderate to severe phonological disorder, I will teach later developing sounds* in an attempt to change the entire sound system (because it is a system, isn’t it?  We have charts that show how place, voice a manner overlap, remember?), and I will teach only initial word position. No painstaking, long-suffering movement through syllables, medial and final positions, and phrases and sentences. Because I’m not trying to replace a learned motor pattern, I’m trying to replace a learned cognitive pattern, or, perhaps more accurately, teach the child something about the phonological pattern of English that s/he had not previously learned from her/his environment.

My definition of articulation is to come, and is much, much shorter than this one. (Yay! I can dig into my book club book!) What do you think of my definition? (That’s right! Now’s your chance to disagree with someone on the Internet!) How do you treat kids on your caseload for articulation/phonological disorders (depending on the definition you personally use)? Does your definition affect your treatment approach?


*The underlying theory behind choosing later developing sounds is that a more complex sound will result in generalization to less complex sounds. A good introduction to this approach to phonological treatment is by Gierut (2001) and can be found in Language, Speech, and Hearing Services in Schools.

So while I’m stuck in the airport waiting for my now hour delayed flight, (Love you too, weather!), I thought I would write up a short post about the post-resume/pre-interview time.  As in,

Q: What to do after you have submitted the resume and are waiting to hear back?

A:  You call a week later to follow up on the resume.

From what I hear, you should try to actually talk to someone within the department (i.e. the rehab manager, or an SLP who works there.)  I have yet to figure out how to manage this.  Probably because I become blind with panic when I get on the phone and am rarely convincing and professional sounding enough (I imagine) to be connected.  If I ever figure out how to do this in an effective manner, you will all be the first to know.  (Or you can give me tips about how to get this done.  Hinthint.)

Until then, at the very least, talk to a human resources (HR) representative.  In fact, within the HR department, I would even check and see if there is a specific representative who works directly with the rehab department, or, even better, with the SLPs.  These people usually have a better grasp on what is going on in the rehab department/SLP division and are usually much more helpful in the information they provide than the average HR person (who will say something like, “Yes we’ve received your resume.  The X person reviews them and passes them on to Y person who will contact you for an interview if your qualifications meet our needs.”)  That does at least let you know that it’s been received, but otherwise for all you know it’s lost in some HR limbo, never to be seen again. On the other hand, if you talk to someone who directly represents the department (or is in the department) they may be able to give you a heads up on what specific qualifications they are looking for and maybe even if another job opening is coming up within the department.  (They almost always know pretty well in advance of the actual posting to the website.) Also, if you are talking to an actual person who Knows What’s Going On, feel free to take the opportunity to try to schedule an interview time while you have them on the phone.

At the very least, the call to whoever you end up talking to, reminds the people there that you are interested in the job…really interested in the job.  And that’s a Good Thing.

Don’t get anyone?  Have to leave a message?  Feel free to call back again in a few days or another week to follow up that follow-up call.  Don’t think of it as annoying them, think of it as showing them how interested you are in working with them!  Questions?  Comments?

Only one more job advice piece to write on salary negotiation, and then…and then…a post or two wrapping up my final thoughts on this whole experience.  And then…we’ll see.

(Sorry for the long delay in posting.  My landlady’s internet has decided to play a long, tortuous game of “I’m working!  Just kidding!  No I’m not!” all week.   So I actually went in with her to work today because I have various things to get done  [read:  job applications] including the other half of this post, which I started almost a week ago.  In any case, hopefully I’ll have the internet back by Tuesday after the tech people come out Monday and return to making posts more regularly.  Again, sorry!)

So, in my last post I mentioned that I felt even going through four semesters of grad school before doing my internship, I didn’t really get the difference between in patient and out patient in a hospital.  It’s all a hospital, right?  It’s all speech therapy, right?  Look, I can’t think about that now because I’m just trying to survive this semester, okay??? ;)

In Patient

My description of in patient may be more extensive than out patient since I have personally experience more of the in patient side of things rather than the out patient side of things.  In patient is pretty much how I described the general outline of my day.  You start your morning by looking for new consults (requests for speech therapy put in by doctors–in the in patient setting this means SWALLOWING 80% of the time).  You then take all the new consults you have and go see them, by which I mean evaluate them.  As I mentioned in another post, this makes your schedule pretty flexible.  If you have multiple consults at a time, you can go see them in any order you wish.  Generally,  SLPs like to take care of the swallowing evals first, because, well, it’s eating.  Doctors, nurses, and the patients themselves, all like to know if s/he can eat or not.

After after the initial evaluation, you need to continue following them until they are discharged from speech or from the hospital altogether. For example, once we do a bedside swallow and determine a safe diet for a patient, we usually follow-up in the next day or two to make sure they are not coughing and choking on the diet we recommended.  If everything is okay (and they are medically stable and/or not likely to make any progress that would change his/her swallow) we would discharge them from speech.  In in patient, though, the patients are rapidly changing (hopefully for the better!).  When you see the patient, it is less evaluation and treatment and more evaluation and then re-evaluation and then more re-evaluation.  In in patient, hospital staff are trying to get the patient well enough to discharge; this is not the setting for long-term goals.  This also means that your caseload has a high turnover rate, unless there is a particularly medically complicated/fragile patient on your caseload.  By Friday, you may not have a single patient on your caseload that you had on Monday.

I love the flexibility this schedule allows (I get to write my SOAP notes right after I see a patient!  Although, if waiting until you’ve seen a few patients is your thing, that’s also do-able on this type of schedule!)  There’s also no danger of getting bored/tired of one patient.  It’s always changing!  It’s also awesome if you really like the evaluation side of thing and are less enamored to the treatment side.  (I mean, treatment does occur, but it is usually more constant re-evaluation.)  If you like solving puzzles and then moving on to the next one without really finding out the rest of the story, then in patient is for you.

Out Patient

Out patient pretty much is what you do at your graduate clinic.  People are scheduled for (usually) hour-long sessions at a time, and it is not uncommon to have 3 or 4 sessions back to back without a break to write a note.  The number of times you see people usually seems to vary with the type of therapy you provide.  T with her language and cognitive stuff tends to see people once every other week for an hour.  M on the other hand, who does a lot of voice, tends to see people more frequently; every day if she’s doing Lee Silverman Voice Treatment (LSVT).  Again, this is probably somewhat affected by M and T’s job description.  M is out patient therapy only, while T has out patients on Tuesday/Thursday, and does in patient the rest of the time.  (CI actually has out patients Monday/Wednesday and does in patient the rest of the time, but he tends to have fewer out patients overall.)

From the week I spent with T, out patient is a very different pace.  When doing in patient, things are flexible and you’re running around everywhere to your various clients.  Out patient has scheduled times, is less flexible, and doesn’t give you time to write notes in between.  (For me, this is the biggest negative.  Not that I’m not used to taking notes about a session and writing up a SOAP note the next day, or even later in the day, because that happened a lot in grad school, but I do personally prefer having the option to write out the note right after you finish with someone.)  The notes also tend to be longer in out patient, probably because you’re spending a whole hour with them working on goals instead of 30 minutes doing an evaluation.  Out patient gives you the opportunity to see your patient’s progress long term (insurance willing), which is definitely not something you see in in patient.  I really like that aspect of out patient.  It’s nice to help people meet goals and have some effective change in their life (well, besides changing their diet or giving them swallow strategies).

Basically, I think if you like a more structured environment and love seeing long-term outcomes with clients, out patient might be more interesting for you.  As of right now, I find both interesting for different reasons.  I think I lean a little more towards in patient right now for all the flexibility and moving about, but I know I’m less likely to be able to do the cognitive-linguistic stuff I love in the in patient setting.  Maybe I should look for a job that gives me the in patient/out patient mix like CI and T have.

If anyone has specific questions or wants clarifications about one setting versus the other, feel free to leave a comment and I’ll do my best to answer (with the caveat stated above that I’m not likely to get back to you until Tuesday at the earliest.  Damn internet.)!

Documentation here is all computerized.  Or well, I should say mostly computerized.  Perhaps I should just say, all the paperwork I do is on the computer.

On this system, all the SLPs can make templates for the type of evaluations/treatments they do.  By and large, they all follow the SOAP note outline (Subjective, Objective, Analysis, Plan).  CI has any number of templates for the evals he might do, bedside swallow, MBS, voice eval, etc.  It makes it fairly straightforward to write a note off of these templates.  There are even certain commonly used phrases included in the template, e.g. “Pt. denied pain with treatment.”  Pain management is an important part of patient care at this hospital for, I think, obvious reasons.  I hope other hospitals I work at as actively pursue patient comfort.

The ‘S’ section generally includes any information about the patient’s emotional well-being and/or level of alertness (e.g. “The patient appeared tired as evidenced by repeated yawning.”  “The patient appeared depressed as evidence by her flat affect and reduced interest in the session’s activities, a change from usual enthusiasm and up-beat attitude documented in other notes.”) or in regards to any information the patient provides (e.g. “The patient reported changing X medication to Y medication.”  “The patient reported coughing and choking after drinking water, soda, and juice.”)

The ‘O’ section is all the objective data.  How many questions on the BDAE personal orientation section they answered correctly, the level of laryngeal elevation based on neck palpation, or observing coughing, choking, and a gurgly voice after drinking thin liquids.  The ‘O’ part usually goes in order of what happened in the session…probably because that’s just the easiest way for me to recall it.  For the swallow SOAPs (both the bedside and MBS), though, it’s a pretty logical progression.  CI is very specific about what he wants in the swallow SOAPs, but that doesn’t make it difficult, see my aforementioned statement on “logical progression.”  I have outlined it below, for the curious.

Oral Mechanism Function

  • Lingual
  • Labial
  • Velar
  • Sensation
  • Vocal quality

Oral phase

  • Labial loss
  • Mastication efficiency
  • Oral transit efficiency
  • bolus formation
  • oral stasis

Pharyngeal Phase (Bedside)

  • timeliness of initiation
  • Laryngeal elevation
  • coughing/choking
  • change in vocal quality
  • change in O2 sats

Pharyngeal phase (MBS)

  • Swallow initiation
  • laryngeal elevation
  • epiglottic inversion
  • Base of tongue/Posterior pharyngeal wall contact
  • aspiration/penetration
  • cough reflex if aspiration
  • pharyngeal pocketing

The ‘A’ section is a summary and interpretation of the data provided above.  (The emphasis on the ‘and’ there was really more for myself.  It just occurred to me that I have really been summarizing more than interpreting my objective data in the ‘A’ section.  No one is ever going to read your whole SOAP outside of grad school, most likely only the ‘P’ section; maybe the ‘A’ and the ‘P.’  I guess they might want to know what the data summary means if they’re going to take the time to read the ‘A’!)  If the patient coughed and choked after drinking thin liquids, this is indicative of aspiration of thin liquids.  A low score on digit span from the Weschler Memory Scale indicates poor short-term memory and therefore directions should be repeated frequently to the patient and probably observed directly to make sure the patient follows them.  And so on….

The ‘P’ section is the plan.  For me, it is usually the standard “Speech to follow 2-4x /week” and perhaps some indication of why we will be following up.  For example, it might be to make sure the recommended diet is still working without apparent signs of aspiration, or to work on orienting the client to person, place, and time.  The goals are also listed here.

In any case, I’m learning CI’s method of writing notes which is as short and to the point as possible.  I can’t speak for all, but in my experience this is largely in contradiction to how we are taught to write SOAP notes in grad school.  In grad school, it’s all about showing what you know.  I thought, by and large, my professional writing vocabulary was pretty good, but my level of short-and-to-the-point-ness was incredibly off.  (We actually discussed this with our program on our final day, and they agreed to more actively advertise the option of writing much shorter, more “real life”-like SOAP notes after the first semester or so.)  I enjoy the notes here much, much more.  I don’t have to write in complete sentences, I get to use hospital acronyms (of which I know .001%), I use a lot of bullet points…it’s fabulous!  I mean, considering it’s documentation.  It is not, I admit, the most fun part of my day.

Pretty thorough, I think.  I feel like I was beginning to master CI’s notes (well, except for the elusive ‘A’ section.  *shakes fist at ‘A’ section*  It’s beginning to come along, though), and now I’m with T for week and the style differences between the two are whiplash different.  Just like grad school:  you learn to how to write SOAP notes for one supervisor only to discover another’s peculiarities are completely different.  Ouch.

*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.

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.

(Re:  the title.  While I whining about my first day and how nervous I still was about the second, to a good friend of mine, she kindly pointed out to me that, hey, no one died; I didn’t kill anyone.  So, in her honor and to enshrine her infinite wisdom, I would like to state:  I also didn’t kill anyone on my second day.)

The day started with the exciting additional orientation to the computer system the hospital uses for documentation.  It wasn’t so bad since I was learning practical stuff I would actually use as an intern, plus there was the promise I would be out of there before lunch.  The only FAIL aspect of this part of the day (which rather unfortunately became a minor theme for Day 2 Hospital, Day 1 Actual Clinical Stuff) was that I was not assertive enough.  (This has been a goal of mine since the beginning.  I’ve come a long way, but I’ve got a long way to go.)  It went like this:  there were multiple modules that different employees (and interns) had to stay for.  Progressively, the class got smaller.  When they called the names of the people to leave after a certain model, my fellow starting intern for PT (physical therapy) was called to leave, but I was not.  Confusion!  Wasn’t I supposed to leave when she did?  We’re both students after all?  I debated on asking the woman to read the list again and see if she didn’t leave anyone off, but I didn’t.  So of course, approximately 5 minutes later when I couldn’t do what they asked me to on the program, they realized I wasn’t supposed to be there.  If I had asked I would’ve left 5 minutes early!  It was stupidly unassertive of me.

Anyway, off I went, getting slightly lost, back to the in-patient rehab wing so meet up with my CI (who will be known as…CI).  Despite moments of FAIL, it was awesome to actually be back to actual SLPing.  We move around a lot since CI sees both in patient and out-patient.  It wasn’t quite as fast paced as I was expecting, which I am not complaining about, I was just a little surprised.  Of course, I’ve gotten the impression from my classmates that it can vary:  some days are pretty evenly spaced out, and other days your are slammed.  And now that I think about it, CI probably built in some time today to orient me to different clinical things, since it was my first day.  Anyway, we would usually review the patient’s chart, go see the patient, and then write-up the SOAP note before moving on to the next patient.  I think I will mostly be seeing swallowing and trachs here and not a lot of language or cognition.  I love language and cognition, but I’m excited to try out some swallowing and trach stuff since that is the kind of thing you don’t see in a university clinic.  Anyway, I kinda sorta lamely helped eval a client (see FAIL list below), but I also wrote my first SOAP note!  Not too shabby for a first day SLPing.


  • was not assertive in electronic documentation class
  • was not assertive enough in the eval (in fact, I kind of missed the, “Now you try” looks CI was giving me before it was finally said, “Now you try”) so I was caught off guard a kind of word vomited my way through it in the most awkward and embarrassing way
  • I am no longer spatially oriented to the hospital.  It will be a long time learning my way around now!


  • I wrote my first SOAP note with minimal corrections!
  • I have made a HUGE effort to learn people’s names and it seems to be paying off…!  (Knock on wood.)
  • No more orientation!


  • Pay more attention to my CI’s non-verbal cues, especially at the end of the day, so I’m not caught off-guard when he wants me to jump in.  (This falls in the same category of problem I had yesterday afternoon when I failed to recognize my CI until he greeted me.)

I will try to explain how patients are distributed among the SLPs in the coming weeks.  I’m not quite clear on it myself, so I’m hoping it will be a little more fully explained in the next few days.