Author:  Klint Goers

Editor:  Elizabeth Campbell

 

It’s 7.30am. I arrive with a coffee in hand, and review the referrals on the wards that have been received overnight.  

I see my first patient, a 38 year old who has been in intensive care and was extubated yesterday, after 2 weeks of ventilator support following cardiovascular shutdown and renal failure.  The patient received a kick to the leg during a game of soccer, leading to compartment syndrome and severe rhabdomyolysis.  He has required multiple surgeries via the plastics team.  Nursing staff have referred to Speech Pathology after the patient coughed with water last night.   My assessment identifies no overt oral motor muscle weakness, good cognition, but severe dysphonia and a weak cough to protect his airway in the event of aspiration.  His dysphagia is likely due to intubation-related swelling, but there also may be an element of deconditioning from the rhabdomyolysis.  After food and fluid trials I clear him to have ice chips, which will hopefully reduce swelling, and also start him on small amounts of moderately thickened fluids, but no food, to practise swallowing.  This small provision of intake also provides an oral route for medications. Despite providing limited nutrition this small amount of intake is a positive step forward for an intensive care patient and can improve patient and family morale significantly.  I speak to the nursing staff about how to monitor for signs of aspiration and let them know that I plan to return tomorrow to reassess after hopeful gains in swallow.  I stress the importance of oral hygiene, not just to keep his mouth moist and healthy but to reduce aspiration of bacteria from his oral cavity that may compromise his chest.  I speak to the medical team, who agree with small amounts of oral intake.  During discussion I agree with the plan for a nasogastric tube insertion for nutrition given his swallow compromise and high nutrition needs for healing.

I return to the Speech Pathology department at 830 for the morning allocation meeting, and help divide the caseload amongst the team to ensure patients receive service equitability.   

I then go to the tracheostomy multidisciplinary meeting.  This meeting has core members, which include Speech Pathology, Ear Nose and Throat (ENT) Doctors, Physiotherapy, a rotating Intensive Care consultant and specialist nurses.  We discuss the current tracheostomy patients in the hospital and any outpatient tracheostomy patients that require team-based input.  A patient is discussed who is awaiting surgical revision of the pharynx after delayed fibrotic changes to the muscles from radiation therapy.  This patient has required a tracheostomy as the airway has narrowed, and he is nil by mouth due to severe oral pharyngeal dysphagia from the same radiation changes.   It’s questioned whether this patient’s swallow will improve after the airway surgery.  I speak up and say any swallow improvement is very unlikely given the degree of fibrosis.  I state that he is likely to remain nil by mouthwith a PEG after this surgery.  I assert that the patient needs to be aware of this when consenting to surgery.  We also discuss a new laryngectomy patient and I agree to organising a speech pathology pre-operative education session to educate the patient on the upcoming surgical changes to his airway, speech and swallow.

The next cab off the ranks is an 86 year old woman admitted to ED after being unable to speak during breakfast with her husband.  A stroke is speculated but the first CT Brain shows no acute changes.   There is confusion whether the woman is aphasic (having deficits understanding or using words) or is having difficulty communicating due to a non-English speaking background.  The patient has been kept nil by mouth until Speech Pathology review as she has a facial droop and mildly slurred speech.  These two factors can be associated with swallowing deficits in the stroke cohort.

Three family members are present.  One says her mother is understanding everything, the other says she is having difficulty understanding and speaking Arabic.  I clarify that the patient has only been in Australia for 2 years and only knows “please” and “thank you” in English.  As an interpreter has been arranged by social work, I manage to grab 25 minutes of her time to do a brief communication and swallowing assessment.  The patient is globally aphasic, in that she cannot understand any instructions, or express her needs verbally.  She says “yes” for all questions.  I demonstrate this to all the family members.  One cries.  I briefly answer some questions based on communication prognosis and suggest how to best communicate with her at present.  I start her on puree foods and thin fluids as she cannot feel the residue in her left cheek and is at risk of choking.  I update the nurses, document and ask the ward clerk to book an interpreter for the next day to complete a longer, more comprehensive communication assessment.

Next on agenda is a staff supervision session for a therapist who is learning to conduct modified barium swallows.   The modified barium swallow is one of two objective swallowing assessments that speech pathology use when we require more information from a standard bedside assessment of swallowing.  A modified barium swallow occurs in Radiology, with Radiographers, Speech Pathology, Nursing staff and usually Radiologists present. It assesses the oral pharyngeal phases of swallowing.  It’s different to a barium swallow that examines the oesophagus.      

The Speech Pathologist has to agree that the patient will benefit from the study before a modified barium swallow (MBS) is scheduled.  As such it can be daunting for new Speech Pathologists to tell a referring medical team that it might not be required, or to advocate for it when we feel it is needed.  In this particular case, one of the doctors has spoken to my colleague to arrange an MBS.  This patient is an 85 year old who was admitted with community acquired pneumonia over a month ago on a background of Chronic Obstructive Pulmonary Disease (COPD).  He has been seen by my colleague a few days ago for a clinical swallowing assessment.  At that time, he presented with breath swallow incoordination and couldn’t manage chewing greater than a mashed diet, as chewing compromised breathing and led to pharyngeal residue.  He did not show clinical markers of aspiration on a mashed diet with small sips of water, and with recommendations to pace intake, and wait for breathing to settle between mouthfuls.  

My colleague tells me that the Respiratory team is concerned about silent aspiration.  Silent aspiration is when a patient does not cough, get a wet voice or show any issues with swallowing, but has a history of chest infection that does not improve.  We discuss the case, and I suggest that I do a second opinion clinical assessment of the patient.  Afterwards we discuss whether we feel he needs investigation.  My college correctly identifies that the patient is too medically unstable to travel to radiology for a modified barium swallow.  We discuss that the patient’s risks for silent aspiration include COPD and also note that that his chest infection is in left side of the lungs rather than the right and this is not a classical presentation of silent aspiration.   We also review his chest history and note no chest infections over the preceding 12 months which lead us to suspect he is not silently aspirating.  I role play the discussion with the medical team with my colleague.  Our discussion surrounds reporting back our opinions, that we feel objective assessment may not be indicated but if they would like to proceed with a study a FEES, or fibreoptic endoscopic evaluation of swallowing, would be our preference as it can occur at bedside.  At our facility ENT will pass a nasendoscope, and the Speech Pathologist will feed the patient and assess swallow function and assess for aspiration.  My colleague phones and details our thoughts to the Respiratory JMO, who reports he will get back to us after he speaks to the consultant.  During the supervision session we also discuss how my colleague’s progress on her learning goals and whether she feels she is receiving adequate support.

It’s lunchtime.  I have lunch with our Speech Pathology team in a patch of sun outside.

After lunch I see four more patients, one on Cardiology who has a hypoxic brain injury with memory and high level reasoning issues after a cardiac arrest, who I have seen for a number of weeks.  He is being discharged home to a supportive family this afternoon.  The woman picking him up is a family member I have not yet met.  She reports “his memory and thinking is off”.  I agree and state that it may be due to the oxygen deprivation during his cardiac arrest.  I demonstrate to the family how to support his understanding by keeping instructions under two steps, repeating key information and re-orienting him regularly.  I demonstrate his reasoning is impaired by showing how he responds to a complex problem, and suggest that at this stage the family help him make healthcare decisions and support him when using money or paying bills.  I speak to the Occupational Therapist to discuss my results of the communication assessment and I agree about referring to support services in the community for monitoring hopeful gains in his cognition. 

I return to the Speech Pathology department at 3.45pm, debrief about my day with my colleagues, and prioritise my caseload ready for the next morning.