Humility

Sometimes you can lose your focus, in the heat of the day. One Friday not so long ago, it was a typical Friday at the adult nursing facility. Patients out for appointments, but the information was not readily available....you double check on the electronic health record or ask nurses, before the shift starts. Surprise discharges, three the night before. There was then the remaining caseload to schedule, with competition for treatment times with the other therapy services abutting your plans. The times at which therapists start their day are staggered, so you may or may not communicate with all your peers immediately. So many progress reports, and updated plans of care to be done. Then it started.

Amongst the treatment sessions, there are new consults to be screened. Family,  requesting meeting times to clarify treatment issues. Reminders that a written status update on some patients is needed, for the insurance companies. When your schedule tells you that a patient is available but the patient is not there, - Is she in therapy? Outdoors/indoors relaxing? Sequestered in the bathroom? Saying "leave me alone; I've had my therapy already". In the beauty salon? At bingo? Taking a shower? Nap time? Family has taken her out for a meal? So many things could be happening.

Then, when all your visits for the day are completed, you are expected to demonstrate that you maintained maximum productivity while seeing all your patients. Your written documentation is meant to portray all that has happened for each person served that day. It should lay out your daily execution of the plan so well, that the parties that pay the bills should not quibble about reimbursement for your services.

If you let this craziness, to any degree, capture and overwhelm your workday - if you let any feelings of anxiety or fear about how complex and random seeming the day is; if you let it infest your work - you are sunk. Dead meat. Yesterday's news. Up the river without a web browser, much less a paddle. A question mark in your supervisor's balance sheet. A worse insult than that one slung by one Presidential candidate against another. It is so hard to keep your head some days, when all about are losing theirs, thank you Mr. Kipling.

How do you combat the urge to run from such a treatment day, if you are the speech-language pathologist on duty in this adult nursing facility? Your training and your experience will tell the tale. How well you live in the moment during your treatment day; that will help you string a successful moment upon a sequence of successful moments. How well you keep to mind, and hold close to your heart, that all this energy is not swirling about for YOUR benefit, but for your patient's benefit - that will lead you to bring that person the best service. Stay humble, stay focused, stay doing what you do.

How I Became A Speech-Language Pathologist

January – from Janus, the Roman god of two faces, looking backward and forwards, probably a prototypical visage for the gardener; another year of growing ends while a new one begins. Gardening is a “yearlong” or continuous cycling of growth and decay; the veteran gardener knows that there is no absolute end to a growing season, but instead there are transitions upon transitions.

A blizzard big enough to leave 23 inches of fine white powder about homes and businesses, is nonetheless paying it forward by providing the ground water as solace for the next season. January is a beginning, yet only an arbitrary beginning. We could be starting the calendar year in November, or even in July.

 But I digress; we have our start to the gardening year in January. We also have now, the start of my story of how I began my career of speech-language pathology (SLP). It was nothing I had ever expected in my quest for a job and a future. But like the gardening year, we don’t know what will be the end of a career until it is the end. Yet In the spirit of this opening, it is also the beginning. Where to start??

I became a speech-language pathologist because – how to say it simply? – It is the helping profession that taps my skills better than any other. I had known I would be in an important profession from an early age. But, Fred Mc Murray couldn’t turn me on to aeronautical engineering, even after I had watched seasons of MY THREE SONS. Neither could Robert Vaughn make me into an espionage operative, after THE MAN FROM UNCLE grabbed my attention for guns and geek stuff. Dick Tracy: could he have helped make me a copper? I flashed my Dick Tracy Fan Club badge to almost a hundred members of a receiving line, after a family friend was married. I was about six, and the receiving line was not impressed.  Nurses are thick among my family members: older sister, cousin, aunt, maternal grandmother...but i neither saw myself as either nurse or physician...In real life, I had changed majors from chemistry to English in my sophomore year. The prospect of a double major in English and history did not dilute the anxiety I felt for the future I had to make.

What made the choice of a career doubly HARD – was that I did well in everything in school, and found that, strictly on the strength of an academic transcript, I could have gone in so many career directions. A depressing situation – but when I had attempted to push through for a BA in English and a secondary teaching certificate, I had learned I had to address a personal problem that had bound my energy and outlined my personality since grade school. I had to undertake treatment for my stuttering. Teacher education students had to pass “general speech”, and my initial presentation to that class bought me little more than notoriety. Get it fixed or your career options have been narrowed, I thought.

The summer session brought my miracle. SLP services had not been available in my local school system. When the evaluation was completed at the university clinic, I was told I had a mild fluency disorder. The feelings I had about myself, and about my ability to communicate and assert myself - they were not mild. I was a Janus creature in my own right. Could I stop being pulled by habits, attitudes and the weight of my past,  learning instead to face only forward, with courage and confidence?

 I learned fundamentals of controlling fluency, and desensitization to speaking situations, then - it was all about putting the skills to work. I acted in a play that same summer! When I found I could change myself and be a bigger me, it seemed natural that - I could learn to do this for the benefit of others. The B.A. was followed by acceptance to a master's degree program in communication disorders, on the same campus.

It was only the beginning of how the career shaped me, and vice versa. More later, on how this SLP career has evolved.

Bag o' tricks

I feel I need to preface all my blog posts with a caveat; with a dead skunk in the middle of the road, or even an "objects may be larger than they appear" warning. When I talk about clinical practice, I speak with the confidence one has after decades of working with - predominantly - adults. Even though I have paid my dues in public school (K-12), preschool and community/residential DD and university settings, it is the folks within the age span from 21-99+ years that have captivated me, clinically. OK. Enough!

Many times I need a special material, or small piece of equipment that can yield data I need to make decisions. The material or equipment is not a capital expense. An SLP will never make enough! But you can't wait, or rather - your person served can't wait to have the advantage you see with this small purchase. Bottom line: impaired communication, as we have seen on many levels in this world, is the compost for evil. To fight evil, you need the right tools.

 
This all started for me, when I took a job for a senior living corporation that provided no work space for the therapy staff. None! There were invariably, needs for my 'wonderful toys' but no place to keep them. Since I ultimately visited eight different buildings in eight communities with this job, the tools needed to travel. Ergo, the bag of tricks.

But, what's in it? Here is a list of what is in my bag today. It grows and evolves. What is in your bag of tricks, clinicians? Please share when you can. Who knows what Santa might bring, to add to your bag of tricks.

 
Opening the bag we see - oh yeah, thank you Ziploc! -

* toy wind instruments (from the party store): harmonica, slide whistle, kazoo; most used? Kazoo!
* toothbrushes for kids
* plastic eating utensils (from take out meals)
* thin plastic balloons
* sugar free Life Savers (individually wrapped), assorted flavors bagged with a box of waxed mint dental floss
* Life Savers GUMMIES - assorted flavors and sugared but, hey, whatever works -
* liquid water enhancer, various flavors
* a package of poker size playing cards
* pen light + otoscope
* a strong and durable pen light - I like the Mag Lite, and preferably in an outrageous color so it's hard to misplace
* individually wrapped tongue depressors
* stereo headphones
* Radio Shack Stereo Amplified Listener w/ 3 band equalizer; SKU #3301097
* stethoscope
* 9 volt, AA and AAA batteries
* quartz electronic metronome
* bottle of bubble soap with wand (lid on tight)
* foam oral swabs
* drierase markers
* assorted pens and pencils
* bottle of hand sanitizer

* infrared thermometer 

* pulse oximeter

* wrist BP cuff

In the grand tradition of SLP's being cost-conscious, creative and indefatigable foragers, I give you the bag of tricks. BUT - get your own!

Horticulture to go - a case of it

I call the speech-language treatment activity "horticulture to go", because it essentially does not let the person you serve - if you serve a facility where people are housed, for medical, nursing and/or rehabilitative care - off the hook. They don't want to come to you, then you can go to them. Start seedlings, cultivate, water, transplant, harvest. That easy. Of course, "to go" means your STUFF has to be portable. In my most recent trial of HTG, I used a shoebox with an attached lid as the garden hardscape. For the actual garden beds I selected

This is the best time of year, as Chia Pet products are heavily marketed for the holiday season.
Two of the herb garden kits supplied SIX terra cotta pots, which filled up the majority of the shoebox space. If you are doing this with a child or adult, fill the empty space with crumpled single pages of newspaper, wedges of styrofoam or any other pliable material that will help stabilize the pots in transit. The rest is so easy!

Though ample instructions for seed starting are in the kit, my direction set reads similar to this:

" I need your help. I want to start growing some herbs, but it goes faster with two persons working. Can you help, please? Good! Here's what we need to do."

After the pots are unwrapped, and wiped clean of any plastic debris: "this is where the seeds will sprout. Now we need dirt."

The soil is initially a dry disc, but when you "add water....", it dramatically swells to take the shape of the container. After the seed packet is opened, I pour out the contents into a clear plastic medicine cup.

Each seed variety is examined, to discriminate it from another, then the person is told " Please pour the seeds into THIS (pointing) pot". Once all the seeds are placed in all the pots, a light cultivation can be done with a TOOTHPICK, or the point of a PEN or PENCIL not being used, or the handle edge of a plastic TEASPOON - any low tech tool will do, to evenly distribute the seeds about the surface of the soil.

You can use that same medicine cup to "pour the water over the seeds in each pot". Six filled cups; one per each seedling pot. SO NOW, the seeds have their SOIL, their WATER - they need, next, their LIGHT and their AIR to sprout and grow. Providing air is easy; when you are not transporting the box about, the lid can be folded open to allow even airflow. But, light?

Though there will be ample sun during the fall and winter months ahead, a light source with sufficient HEAT (like the gooseneck lamp I have) comes in handy to accelerate the germination (POP!) process. What happens as a result of all this?

My most recent foray into HTG, has a woman in her mid 80's who is normally recalcitrant about therapy - smiling and saying she wants to keep at least SOME of the plants she helped start. Who knew?
HTG. Try it and see!

My thanks in this blog post, to Joseph Enterprises for all their creative and marketing legerdemain in putting the "Chia Pet" empire together. You can get information on their products, including the herb garden pictured above, by going to their website at http://www.chia.com.

The transitions

I forgave ASHA for depriving male attendees of hygenic resources, during this year's Denver Convention. 4% of the membership deserve 50% of the stalls? FIE! Let the men all desiccate into dust and be blasted home on howling winter gales! Sorry, dehydration mania.

It's the last day of convention, and I feel myself tugged - looking in two directions at once. Like Faulkner said, the past may not even be past; but  - and the original statement is copyrighted so, be kind Apple - you had better have one of those teeny tiny programs that do fun STUFF, for that -

I have attended ASHA conventions off and on from 1974, when it was in Las Vegas and I was an undergraduate in search of a career. Since that convention, the Association has never returned to Vegas. Giantesses and giants alike in the professions have blazed numerous trails of discovery with rigorous method and proven results, so that the people we serve can blaze their own trails as powerful, interactive individuals. Conventions have served to not only celebrate accomplishments, but also to charge us to search for more.

And, would you fill up my water bottle while you're at it - yeah, at that fountain right there - thanks!

What are we becoming as two professions; audiology and speech-language pathology?  It's the height of magical thinking, to assume that today's professionals can just bypass all the technological, regulatory, business model, legalistic, political warfare, cultural Hatfield v McCoy types of changes; all those and more, whirling us around every day like ingredients for a
Venti Iced Skinny Hazelnut Macchiato, Sugar-Free Syrup, Extra Shot, Light Ice, No Whip - ??

We have to live in the world where our consumers live; where they communicate, move, think and swallow . But do we have to be swept along by it til pureed? We are charged to help the persons we serve, find the tools they need to maneuver the world in which they live. The convention sessions on wellness, mindfulness, stress is your friend, etc.; - all are part of our professional lexicon, none too soon.

The more stable and resourceful we are in all our life settings, the better we are at serving as shelters from the storm. Thank you, Mr. Dylan. An example of our need for both resources and resilience?

Greenslade, Hutchins and Prelock, session 1607: 4 out of 4 hammers; -
I will never cease to amaze myself. First, an audiology session and now - well, I have not had a child consumer on my caseload for three years. But there are great scientists-clinicians out there, not just building the corporate theories of mind, but also empowering families and communities for persons with ASD, and standing alongside their persons served, to enjoy life. Those in the meeting room who saw the 17 year old, on video, express empathy for his mother who (not really) whacked her finger with a hammer - if you were not one of the group that let out an "Awwwwwww!", you immediately wished you had acted on what you had felt inside.

The union of science and human contact: this has been, is and should always be the core of our professions.

Back to the poster sessions, as I prepared to rush to the airport. A poster at which I had paused, appeared to me to bring this issue to focus. A doctoral candidate from a southern US university presented  her research, on assessing attentional impairment after brain injury. Her data was impressive, but her excitement at reporting what the data revealed - it made you glad you were masochistic enough to finish advanced study in this field.

Lucky me. I ended convention on a high note. Back to work now; we'll take this up again in Philadelphia next November.

Drink plenty of water, but this is not your bathroom!!

It all started when I flew into Denver this past Tuesday, and immediately began to suffer the effects of altitude sickness. According to a Los Angeles Times article on Lady Gaga, being hit with altitude sickness on a 2014 Denver concert swing, altitude sickness has symptoms that include headache; anorexia, nausea or vomiting; fatigue or weakness; dizziness or lightheadedness; and difficulty sleeping.

The Denver.org website (to which ASHA conventioneers were directed) reminds us that the best symptom relief for altitude sickness is HYDRATION - drinking, in fact, up to twice your normal intake when at home.

The second day of the ASHA Convention ensues, and I am reminded again that, with my newly hydrated status, I will have to walk up to twice as far to find a men's bathroom at the Convention Center. Many men's bathrooms have been converted to women's bathrooms for the duration. Hmmm I have dressed in drag a few times, but not now - the sessions are starting!

Kudos to the Colorado Convention Center (CCC), and to the ASHA Convention co-chairs, for generally comfortable facilities and amenities. I am guessing that, having no water dispensers in meeting rooms, and signs that encourage careful use of water in bathrooms, reflects the realities of western drought. You gotta buy that water, baby! Right over there - go stand in that line and they'll sell you all the water you want!

Whew, just in time. Scribbling furiously -

*Aaron Ziegler, Aaron Pham and Joshua Schindler, session 1342: 3.5 of 4 C major triads; a model of the seamless joint work of MD, Pharm.D. and Ph.D., CCC-SLP in a university voice clinic was well portrayed. There were sufficient references to help participants,  who need to research the ingredients patients choose to self-realization their voices. A case study may have helped illustrate the role of the Pharm.D. in treating the clinic patient.

*James Coyle, Steven Leder and Gary McCullough, session 1385: 4 out of 4 Toothettes, for the fireworks alone! I am sooo indebted to Dr. Leder, as he has not let die the fine old art of debating convention papers in real time. It's rare now in sessions, to see the University sensei wage combat over a reference, or fillet a statistic until there's no there, there. Is the CSE a "common sense examination"? Gimme that 3 ounces of water, and let's move on.

*Sarah Blackstone and colleagues, session 1396:4 of 4 switch ports; the AAC community are very well prepared for the new world of patient-provider communication. As the panelists had been collaborating to get out the recent Plural book of the same name, each facet of the concept connected well to the others. Cultures to be changed, yes.

*Anna Meehan and colleagues, session 1470: 3.5 out of 4 saccules; I was an SLP in an "audiology session", but they did not smell my fear. I wanted more background on pathophysiology, and a better picture of  the thinking behind differential diagnosis for military MTBI.

The first author had apologized for not having video that explained the mechanisms of injury. Another video to illustrate the diagnostic clinic process, with emphasis  on showing the MTBI patient's presentation, would also have helped. Will hyperbaric oxygen treatment help these veterans?

Boy, I'm thirsty after that but - NOT YET.

*Paul Rao, session 1498: 3 out of 4 policy manuals; cultural competence as a lecture topic at 5 PM is very challenging, but Dr, Rao's witty connection with the audience made the experience work. Large blocks of text that are read from a slide, does not easily engage the audience in an important objective for our professions. Reaching back to refer to the Blackstone et al. panel, and the informal exchange with the 15+ person audience, pulled you in to commit to greater competency back home.

Whew, what a day! And in memory of the innocents massacred in Paris on Friday, we'll segue into the evening (awards ceremony, open houses) with Greg Brown's "Laughing River". Since the copyright police are as thick as the HIPAA police, please "youtube" it.

See you tomorrow for final sessions and a scramble home.

A patient's wishes should really matter, or - we're glad we're not old.

This was the first day of ASHA's 2015 national convention, held in Denver at the Colorado Convention Center. Yesterday's snow became today's chill, and the assembled professionals came out of the 8:00 keynote session loaded for gaining knowledge. I began my day by attending a swallowing track that was attended at capacity. What I carried away from my sessions, totally unique from the body of sessions others at this Convention are attending - included:

* You should be glad you are not "old" - subtle jabs at the older faculty, to those of us who have been in the field for awhile, and by extension, to those older persons we serve, that - it stinks to be us!

* "There are squamous, columnar/esophagus tissue/Schatzki, hiatus//sarcopenia - ewwww!/When dysfunction strikes/let's recall what the patient liiikeeessss.../Eating is complicated/...."

* James Coyle, session 1040: 3 1/2 out of 4 hyoids rating; his delivery was rather rapid but - a lot to say! Great foundational lecture for the next one -

* Joseph Murray and Paula Sullivan, session 1085: a 4 papillae performance. We do this job to improve people's lives, after all, and this session squeezed in some tips to help the frail elderly sustain quality of life.

* The quality of poster sessions so far; their breadth of topic and clarity of argument: a rating of 3 out of 4 hair cells. Three posters on hippotherapy alone!

* Kimberly McCullough, on cognitive wellness, session 1171: she was so preaching to the choir that I had to be content with fingerspelling AMEN!

She did such a good job of dovetailing her work, and that of her co-author Kathryn Bayles, with the keynote address of Kelly McGonigal - that I WILL buy McGonigal's book, THE UPSIDE OF STRESS.

McCullough gets 3.5 out of 4 glial cells, however, for keeping the actual clinical science of cognitive wellness fairly romantic. One of my few claims to fame in the field came, when I made David Yoder blanch at an ISAAC conference, by linking AAC with 'romantic science'.

 I offered her some help in applying the paradigm shift to clinical practice - think of a demonstration garden on the Appalachian State campus. It provides opportunities for stress reduction in an environment offering mindfulness. It provides the participants material for practicing prevention of cognitive - communicative and swallowing impairments. (I am shameless, but that is one thing convention is about).

DAY 2 of convention beckons. Won't you come along?

when it is fall here....

This blog originates from zone 6b, designated as such on the United States Department of Agriculture hardiness zone map. First devised in 1960 to explain the effects of variations in climate across the country for growing plants, the USDA map describes the hardiness of plants for zones  1 through 13, from Alaska to Puerto Rico.

Defining hardiness as a function of average temperature ranges, hardiness zones help a farmer/gardener select plants that will thrive in their region. The speech-language pathology community that is involved in gardening, as part of its clinical mission, knows that peers who share about gardening may sometimes compare apples and oranges, but - how do they find a fresh apple or orange in October? Let's look briefly around the nation to see what a gardener can do during this month.

*Duluth, Minnesota - In the north central lake country, Duluth is a landmark for those traveling the Mississippi.       

                                                                                                                                                                    It lies within hardiness zone 3. Most of the Duluth area's 31 Farmer's Markets are closing for the season. Apples come from the market area of St. Louis, Carlton and Lake counties. St. Louis County, of which Duluth is the county seat, has its extension office in the courthouse building. Three miles away is the Pierce Speech, Language and Hearing Clinic, at the University of Minnesota - Duluth.  

The home gardens in the Duluth area are still harvesting: beets, broccoli, cabbage, carrot, celery, cucumber, garlic, kale, leek, lettuce, melon, okra, onion, peas, peppers, potato, pumpkin, radish, spinach, squash, chard, tomato, and watermelon.The price of an apple ranges from 77 cents per pound of Braeburns, to 1.99 for a pound of Gaia or Fuji.

*Hayward, California - the East Bay area keeps average temperatures significantly higher than Duluth, as Hayward is within hardiness zone 10.

October in the East Bay brings not only harvest of the plants available from the Duluth area, but also plantings of beans, Brussels sprouts, cauliflower, leeks, and parsnips. California State University, East Bay, has its Norma S. and Ray R. Rees Speech-Language and Hearing Clinic, within the Music Building on campus.

14 miles away is the local office of University of California Cooperative Extension, in Alameda. A trip of 2.5 miles from the University brings you to the Hayward Farmers Market. It is open year round.

Granny Smith apples are 99 cents per pound, honey crisp are 1.48.

*Barrow, Alaska - In zone 2b, Barrow seems on the surface the type of locale farthest removed from areas of the country that garden. To be exact, the distance from Barrow to Hayward CA is 2632 miles;  from Barrow to Duluth, 2693 miles.

But, recently emerging on the North Slope of Alaska at Ilisagvik College, is one site for "arctic gardening", where outdoor barriers such as cold frames can insulate seedlings and transplants against the cold.

Ilisagvik College does not have a speech, language and hearing clinic. The Old Farmer's Almanac, source for the planting information in this post, says that crops that are easiest grown in the Barrow area are lettuce, radish, spinach and chard. Farmers Markets in Barrow? No, not yet, but the college may find itself its parent.

A pound of honeycrisp apples in local markets goes for 3.97.

*Columbus, Ohio - USDA hardiness zone 7 surrounds the home of the Ohio State Buckeyes.  Its speech, language and hearing clinic is housed within Pressey Hall on campus. Beekman Park surrounds the clinic on its north face. 0.6 miles away is the OSU Extension office, within the Ag Administration Building.

Up to 12 Farmers' Markets can be found around the city, with closing dates through early December. OSU also has a Department of Horticulture and Crop Science, where new horticulturists are born. In October, the harvest in Columbus includes beans, beets, broccoli, cabbage, carrot, cauliflower, celery, corn, cucumber, eggplant, garlic, kale, leek, lettuce, melon, okra, onion, peas, peppers, potatoes, pumpkin, radish, spinach, squash, sweet potato, chard, tomato and watermelon. And, at apple harvest time? Macintosh apples are at 88 cents per pound.

There are many similarities in garden seasons and commodity prices, across the USDA hardiness zones. Careful breeding of plant varieties and the well-run national marketing of produce product helps keep food prices low, and fruit/vegetable varieties easy to grow across the zones. Speech-language pathologists who include gardening in their clinical armamentaria, will have lots of opportunities to share their clinical findings with peers across the country.

The differences among zones are as intriguing as their similarities, for the variety of clinical outcomes one might achieve with a clinical gardening program. They have yet to be explored, to determine their full efficacy.What will future SLP clinicians accomplish toward this end? The future is ripe for picking.

Gardening aids in speech therapy: a primer

1. Look at your treatment plan, the blueprint for what needs changing with therapy.
2. Example: "the patient will name on demand, ten of ten objects common to her/his environment, with vocal/gestural/tactile/olfactory cues provided 100% of the time".
TELL ME THE NAME OF THIS!

3. That is treatment at the level of IMPAIRMENT of bodily function. When you see significant improvement of that behavior, you want to help the person take this skill set back to real life. Gardening allows the client to ease back into real life, or the PARTICIPATION level of function.
4. So, when it comes to identifying summer annuals that must be removed from garden beds, one needs to name these plants.
5. Your client will practice naming these summer plants:
A. Tomato

B. Zucchini
C. Cucumber
D. Eggplant
E. Marigold

F. Basil
G. Pole Bean
H. Cowpea

I. Bell Pepper
J. Corn
6. If the client does not spontaneously say the name of the plant when seeing it, a card can be produced which has a COLOR PHOTO of the plant, the PLANT's NAME written in BOLD PRINT adjacent, and some general information on the plant's LIFE CYCLE below.
7. The client can match the photo to the plant, or -
8. The client can imitate your naming of the plant. 
9. Successive experiences in the garden allow you opportunity to increase the client's skill level, to meet the goal set in the treatment plan.
10. Dig we must!