Slow Therapy

I had picked up a copy of the 2012 publication GOD'S HOTEL, by Dr. Victoria Sweet, so that I might gather background, then read another book with a similar theme. I discovered that Sweet ' s memoir of her career at Laguna Honda Hospital, the nation's last almshouse on the SW side of San Francisco, could have described a hospital where I once worked. GOD'S HOTEL deserves a careful look in its own right. In the evolution of my own SLP career, I have done quite a few Laguna Honda things. Like the country's last almshouse, my employer had been doing some medical care differently. But first, why the title? "God's Hotel?".

One function of the medieval hospital, grown out of the monastery, was to offer not only opportunities for healing, but also for social welfare; hospitality along with care. The SLP, especially in the medical setting but impacting every setting, lives that balance every day as a steward of communication and swallowing. Were there time and space in a setting like Laguna Honda, for taking time and space to bring quality service to all?

In France and other countries that hospital was called the "Hotel Dieu"; one had even existed in New Orleans, from the mid-nineteenth century until the time of Hurricane Katrina. Just like these institutions had fulfilled unique roles in the healthcare system to serve the poor, San Francisco's Laguna Honda had existed for those persons having nowhere else to go when ill. The physicians and staff had had the time and the resources to care for those persons.

Dr. Sweet had helped grow at Lagunda Honda the concept of ' slow medicine', to describe how she took ideas from 'premodern' medicine (p. 139); specifically, how the writings of the abbess Hildegard of Bingen inspired her dissertation on one approach to nourish and restore the life force of a patient  (veriditas = 'green truth'). In this view of healthcare, the patient is a garden to be tended, not a machine to be repaired. This approach is not compatible with the modern healthcare system, but occasionally with my employer there were openings with an individual patient that made me think - something else was possible.

With slow medicine in the form of gardening therapy, there were approaches to engaging patients at Chicago's Michael Reese Hospital that led to more successes with more patients.  With the open mind that it fed, - a mind open to creativity,  to individuality and compassion -  slow therapy was one sterling example of caring for the patient. Sweet cited in GOD'S HOTEL (p. 91) as a huge precursor of her work, the writing of Dr. Francis W. Peabody. Dr. Peabody is quoted - "...the secret of the care of the patient, is in caring for the patient". 

Slow therapy made its mark for me at MRH, when I was bringing patients out the east doors of the rehab unit, to work the plants and keep them healthy until harvest.  Gardening sessions allowed the patient to find her/his voice, while conducting routine gardening tasks (cultivating, weeding, watering). Individualized session activities stimulated and tapped the skill sets for cognition and communication. Then, just as the institution named Laguna Honda became a new medical center with new ways, so did Michael Reese become - a memory. 

Was that the end of slow therapy, as Laguna Honda's transformation appeared to be the death knell for slow medicine?

What just happened?

Leaving an SLP session, whether it occurred in a dedicated treatment room, an office, corner of a classroom, someone's living area, the kitchen table,  the bathroom sink, over a plate of food, under the best of intentions, or between meeting time, bite-o' lunch time, and report - writing time, analysis of a professional visit makes you feel good because you find often, that you are in control. The boss may peek in occasionally, and if you are an incipient or new professional, you're under the watchful eye of a clinical supervisor. What just happened, they might ask - !? But of course, you are not asking that question solely when the session has ended.

Before it even starts, you know how you want it to end. As you engage in the activities you have planned for your person served, your path - your trajectory - your connection to your objective flexes and changes continually, like a space vehicle's trajectory before landing on a 'heavenly body' continually changes as YOU approach IT. You ask this question then, many many times. Many, many, numerous, known and unknown variables influence your getting to the end. The person's skill set, or yours. Interruptions. The rhythm, the pacing, the emphases placed and the importance for insight vs. mastery. Then, as the clock ticks down the minutes remaining in the session, your decision making may center on only a few variables:

* Did the person you served get it? If the session focused on treating the impairment, were impairment - based activities getting buy-in from the person served? On the other hand, if training to increase performance on an impairment based skill made no sense,  - would there be an advantage to using participation based, real life activities?

* what does the data say? It is the arbiter upon which we depend, to determine clear evidence that the activity in question works. Trust your data collection, when it reflects your powers of observation and the variables you chose to control for, Find any trends and ask, "What does it all mean?".

* does the person hold what you do, and by extension YOU - in greater regard? As a professional, you are obligated to serve the person; not necessarily, to develop an acquaintance or friendship. But, one reason that communication is "pretty wonderful", is that it enables people to touch each other; to make a difference. A good session may sell the person served on doing another, and another, until some goals are met. Yes, ask promptly "what just happened".

Pneumonia and its Discontents

I anxiously began last night to read a book just published (6/6/16) – and, like W.C. Fields with the Bible, I was looking for loopholes. MULTIPLE SCLEROSIS: Coping with Complications (Archway Publications) is Dr. Barry Farr’s perspective on his 24-year dialogue with the disease. Farr is Professor Emeritus of Internal Medicine, with specialties in infectious disease and epidemiology, at the University of Virginia. I was a year behind Barry Farr at our Mississippi Delta high school, and was sponsored by him into a social fraternity at the University of Mississippi back in the day.  Farr has done pivotal research and published on such topics as surveillance of Methacillin-resistant Staphylococcus Aureus (MRSA), alternating air pressure wheelchair cushions, and the use of silver-coated urinary catheters by hospital patients . 

                                                                                                                                                                                                                                                                                                                                                                                                                                The Society for Healthcare Epidemiology of America (SHEA), has since 2006 awarded the “Barry Farr Award” to the author of the most outstanding paper published each year in their house journal, Infection Control and Hospital Epidemiology. So, this author has serious chops for clinical observation and research methodology, and he has applied them to present to the reader, strategies to help the MS survivor increase her/his quality of life. But, why am I looking for loopholes in Farr's narrative?

In Chapter 31, "Preventing Pneumonia", Farr says that a treatment for dysphagia that involves exercise lends little to any prevention effort: "There doesn't yet seem to be consistent evidence from randomized trials documenting significantly lower rates after swallowing exercises" (p. 252). He is taking food out of the mouths of my grand dogs, might be my stereotypical statement on this issue. That's right, my child has dogs. Yet to date, there is no evidence that exercise based treatment makes a significant difference in the bodily impairment; that is, the efficiency of swallowing for persons with MS. Exercise may instead, make a difference in phenomena that impact the swallow. One example of a correlated phenomenon is the cough. As Farr comments at the beginning of this chapter, "Vigorous coughing in a patient already suffering severe pain....also makes the pain worse with each cough" (p. 247).

 

Speech-language pathology would argue that exercise-based rehabilitation of speech and swallowing impairments, holds some promise. For example, expiratory muscle strength training (EMST) is a treatment modality enjoying a lot of research interest, and that may hold promise for increased cough control (Sapienza and Troche, 2012, pp. 56-57). Cough suppression therapy may also contribute to increased success with non-pharmacological management of the condition (Chamberlain, Garrod and Birring, 2013).

But Farr leaves some valuable observations as well, about how his attention to his posture; his rate per swallow; his sustaining attention on the swallowing act, rather than switching focus to and from his social connections at mealtimes; and heightened interest in oral care, with emphasis on flossing - all these strategies implemented, raise the odds for success in pneumonia prevention. Some of these strategies are discussed in refereed journals (Langmore and colleagues, Dysphagia, 1998), and others are reported anecdotally by clinical 'grunts on the line' like this writer. 

I joked earlier that Dr. Farr's comments about speech-language pathology were impacting my livelihood. That really is not a worry of mine. Earlier in my career, I felt doctors were casting aspersions on the field to such a degree - something need be done. One of my prized possessions is a handwritten letter from the late Oliver Sacks; it was his response to my rather heavyhanded critique of his piece "Recalled to Life" in The New Yorker (10/31/2005). Aphasia, treated by MUSIC THERAPY?? I calmed down after receiving Sacks' thoughts on the matter. All is forgiven, Brother Barry. Good job. 

SELECTED REFERENCES: 

1. Sapienza, Christine M., and Troche, Michelle S.  RESPIRATORY MUSCLE STRENGTH TRAINING: Theory and Practice. San Diego: Plural Publishing, 2012.

2. Chamberlain, Sarah, Garrod, Rachel and Birring, Surinder S., "Cough Suppression Therapy: Does It Work?", PULMONARY PHARMACOLOGY AND THERAPEUTICS, 26 (5), March 2013, 1-4.

3. Langmore, Susan E., et al. "Predictors of Aspiration Pneumonia: How Important Is Dysphagia?", DYSPHAGIA, 13 (1998), 69-81.