Hooray, you can talk. Next.

Thought he couldn't swallow for shucks
But he wasn't so bad
And then she was so aphasic
That I went the AAC path
I stopped short of giving up
When I repeated the testing
And my patient could say 'Thank you'
'Cause he got some help, addressing

How to articulate 'love'
Then how to write down 'I'm so happy'
And then, he gestured 'I don't know'
SO my day feels kind of crappy!

I've treated and I've trained
But, have I gotten anywhere?
O yes, you're all in the game
Look at all that you can bear
And for that, I say

 You can talk, next! (next!)
You can talk, next! (next!)
Keep on talking, next
I'm so fatigued but I'm not hexed
You can talk, next (next)
You can talk, next (next)
You can talk, next (next)
I'm so fatigued....

 

A real person, brain injury survived, life ahead, what?

The first time I had met with P., he was new that day to the rehab unit. The ambulance transferring him to our unit had scarcely left the drive, on the way back to the University Hospital, when I assured myself my plan was on point.  No one had taught me this, but I knew I had to imprint on this guy.

I needed to be the first therapist with whom this patient could bond. And now I was here for the initial bonding experience.  Through review of P.'s record, I could flesh out his story to decide on a tentative plan with P., his family and support system.

"P. my name is C. I am a speech therapist. It's good to meet you. You are at our rehab  center. I'm here to help you anyway I can"...and then I sat back and listened.

P. had been shot in a drive-by assault, some six weeks prior to the day he had entered acute rehab. The trajectory of a single bullet, entering his right forehead, had at high speed dug deep into his midbrain, with a cavity swelling then imploding around that missile. Brain tissue density  did indeed change the bullet trajectory, so that the bullet exit wound was found through cerebellar tissue at the lower left cranium.

"P., with what happened to you, I have seen in your chart that you do not talk. You are able to concentrate on a person, when that person touches your arm or shoulder. You don't swallow your own saliva without coughing, so there is a tube in your stomach so that you can be fed".

While the abrupt trauma to P.'s nervous system had brought about his coma and near herniation of his brain stem, - what had been turned off, at the neuropsychological level, were consciousness, alertness, attention, speech, expressive language, and all the higher cortical functions - what make you an adult...they're turned off, for awhile.

P. had been found on an urban street corner by the EMT's, not five minutes after the gunshot had been documented on high- sensitivity audio police surveillance. He was known to the city's police; not having completed high school or a GED, his job had been on the streets. The state had begun to pick up the tab for his highly complex medical care through Medicaid. Acute rehab was intended to get P. more mobile, more independent for ADL, and communicative.

"OK P., it's time now to help you get better. I can't guarantee we will reach a certain goal, but we are going to try to help you swallow better. Here -here is a cotton swab, with some lemon ice coating it....I'm rubbing your lips with it.  As the President says, we'll see what happens".

I am always open to pleasant surprises...but after doing this kind of work for over 35 years, the odds for P. having a future in competitive employment is extremely low. P.'s need for long term complex medical care seems to be high intensity and long-term. As of our first day, the social worker says no one had yet been arrested for this shooting. Why did we have to have this case?

More guns than there are brains

* US Population Estimate (January 2015): 320,000,000

* Number of guns privately owned in US (January 2015): estimated, 265,000,000

Source: Azrael, Deborah, Lisa Hepburn, David Hemenway, and Matthew Miller. 2017. “The Stock and Flow of U.S. Firearms: Results from the 2015 National Firearms Survey.” RSF: The Russell Sage Foundation Journal of the Social Sciences 3(5): 38–57.

 Significant determinants for outcomes after gunshot wounds to the head include:

* Admission Glascow Coma Score (GCS),
* Trajectory of the missile track,
*  Pupillary response to light,
*  Patency of basal brain cerebrospinal spaces (CSF cisterns) were significant determinants of outcomes in civilian and military gunshot wounds to the head.

Source:"Gunshot Wound Head Trauma", web page managed by the American Association of Neurological Surgeons.  http://www.aans.org/Patients/Neurosurgical-Conditions-and-Treatments/Gunshot-Wound-Head-Trauma ; Accessed 8/1/2018. 

"Not all bullets are created equal. The energy of a bullet is determined by its mass and speed, and its wounding potential hinges on its ability to transfer its energy to a target; even rounds that are similar in size, or look similar, can cause dramatically different damage."

Source: Meredith Rizzo and Rebecca Hersher, "WATCH: The Science Behind Why Some Bullets Are More Destructive Than Others", SHOTS: Health News from NPR. Washington, DC: National Public Radio. https://youtu.be/UzXsjMDpNq4 Accessed 8/2/2018. 

"Gunshot wounds to the head, the most lethal of all firearm injuries, rank among the leading causes of head injury in many United States cities. They carry a fatality rate greater than 90 percent, and at least two-thirds of the victims die before reaching a hospital."

 "The bullet trajectory through the brain carries major significance. Bullets that cut through the brainstem, multiple lobes of the brain, or the chambers where spinal fluid is located are particularly lethal.Many initial survivors develop uncontrollable pressure on the brain and subsequently die."

Source: UCLA Neurosurgery, "Cranial Gun Shot Wounds". Los Angeles:  UCLA Health. http://neurosurgery.ucla.edu/cranial-gunshot-wounds ; Accessed 8/2/2018.
 
The first time Reed opened fire on a rival gang member, he says he got hooked on shooting.
“It’s like an adrenaline boost. Like ... I’m da man!” he says. “You know, I enjoyed it.”
Growing up on the Northwest Side of Chicago, Reed says gang members kept guns in a Crown Royal bag under his front porch. He says after he committed his first shooting, at about the age of 13, he was always chasing that rush — and would often volunteer to go with his fellow gang members when they went out looking to shoot rivals.
“It’s like a drug. You get addicted to living the lifestyle, living the gangster lifestyle,” Reed says. “Since I was a kid I always was infatuated with that type of lifestyle. Always.” 

Source: Robert Wildeboer, "When Shooting Feels Like a Drug". Chicago: WBEZ 91.5 Radio.  http://interactive.wbez.org/everyotherhour/like-a-drug/ Accessed 8/2/2018.

"My identity as a gun violence survivor is a paradox. On one hand, it's a reminder that life can change fast, in unimaginable ways — in my case, a gunman opened fire on me and my constituents at a community event seven years ago, killing six, injuring 12 others, leaving me partially paralyzed and reducing my ability to speak. On the other hand, tragedy has given me agency, courage and historic purpose in the movement to save lives from gun violence.

As a survivor, I’m often sought out to comfort those in distress. People send emails, write letters, leave messages on Facebook, but usually, they just stop me on the street. Many times, they have their own experiences with pain and trauma — often left unmentioned — but their survivorship is marked by a recognizable resilience."

Source: Gabrielle Giffords, "Getting shot seven years ago gave me courage to fight gun violence: Gabby Giffords", USA Today. Washington: Gannett Corporation. https://www.usatoday.com/story/opinion/2018/01/08/seven-years-after-being-shot-were-still-standing-up-gun-lobby-gabby-giffords-column/1011400001/ Accessed 8/2/2018.

Inside my head, your care in my hands

"Hello. I've been running my tail off today. I wasn't sure I had gas in the tank to be here with you....and now your meal is an hour late, so your frustration tolerance may be even more frayed than mine! No matter, I'm your man now. It's time to eat; may I help you?"

May I help you eat your meal? I see you've got (meal items). I'm going to just take a few seconds and (prepare) your plate. There; now it's time to start. I hope you're hungry! (There is your utensil) (Let me scoop up a bite for you)....what do you think? 

"Hmmmmmmmmmm....I am watching you for a bit; do you feed yourself or not? It makes a difference for how well you swallow, but - no matter. Eating is not just a survival act and a cognitive act. It's a social act, too! Let's get to know each other a bit as you eat. Whatever I can teach you to do, I will also teach the staff who work with you. Ready? (holding up the utensil, stationary, so you can see it and open your mouth - before I bring it to your mouth). You see how I place the bite of food inside, so you have to make an effort to pull it off the utensil and start swallowing?? I like how people swallow more easily, when food is not just dropped at the front of the tongue. Now, here's another bite...."

I am going to help you eat; is that OK? (about 3 seconds for person served to respond 'yes') Good, thank you. (Utensil lifted, a bite of food cut from portion served into  bite-size pieces). Ready? (utensil avoids 'clacking' teeth or scraping cheek, so the bite rests on the Middle/posterior tongue). I watch you swallow, before presenting the next bite....

"WHAT? WHAT DID YOU SAY? It's the staff; she said that I was feeding you too slowly, and you were criticizing how I fed you with your eyes.  First of all, if they were doing a thorh job about feeding you, they wouldn't have had to refer you for a speech-language pathology evaluation. If all I were doing was feeding you, second of all, - I might do no more than drop the spoonful inside your lips. I do want to give you assistance that make your more readily swallow, as well as swallow safely. We'll get up to your speed soon enough."

I like how you looked at me intently. Don't worry; I'm not stopping your meal. I wanted to see how well you were paying attention, and - YOU ARE.   Here's another bite; ready? Good, I'm glad you are enjoying that....A cough? Yes, cough it out well. A strong cough is an important skill to have. Good then; can we keep going? OK, here's another bite; another sip. Oops! That mess is my fault. Good, and another - another - you're doing quite well today. 

"I do want to do a number of these observations of your eating and drinking. A sufficient sample size of them, and each of them being not cross-sectional but longitudinal.  I want to see you consistently eat and drink, while using these skills and strategies we have tried today. What do you think? I don't want to change your diet unless absolutely necessary. Can we do this?"

Untangling tongues with things

Better Hearing and Speech Month 2018 is  over. We've bypassed National Joke Day; Workaholics Day, and even World Emoji Day. There's a lot still that can make us happy, about our potential for bringing a better quality of life to people we serve as SLP's.

In spite of decreasing program budgets, increasing controls over reimbursement, productivity targets for clinical practice that threaten making persons served, widgets; the challenges to our clinical foundations, through disciplines fighting over who will serve; even, will persons having needs, be served? - there are innovations, breakthroughs and standards upon which practitioners can stride, and see the next bright vistas for the professions. There are so many interventions that can be celebrated: I can take one in hand.

I owe thanks for inspiration to Katie Schwartz (Alt Career Options), as well as to Gayle Van Tatenhove (Core Vocabulary Classroom Kit) , Julie Tracy (Urban Autism Solutions), Beth McCauley (Animal Assisted Therapy), Rachael Baethge (Speech/Language Skills at the Zoo), Matthew Crawford (Shop Class as Soulcraft; The World Outside Your Head) and Kelly Lambert (Natural Enriched Environments)....and all those not mentioned, who have helped grow the field with instrumental, non-traditional approaches to treatment.

By instrumental, I point to instrumental activity, or what is called 'handiwork'....instead of picking up a  picture card, pick up a ball or a horse's reins. When you are bored with squeezing or pointing, substitute digging or watering. Have you done all the stimulus-response work in the clinic, you can abide? Get out into real life, and practice the skills where persons served will ultimately use them.

Why handiwork? The rich, abundant and emotive energy of everyday life is largely driven by instrumental action: we live through eating, painting, writing, driving, exercising, praying, and so many more actions that are mediated by communication. The writings and teaching of these innovators will remind us clinicians that communication:

* does not just happen in quiet spaces;
* often occurs when persons served are performing an action of daily living;
* requires the clinician to manage multiple, complex variables to help persons served to reach a functional outcome;
* provides outlets for persons served, to sustain and increase emotional health, in conjunction with cognitive communicative health;
* is how you do things;

Let's communicate where we live!

Could I ask for what I wanted?

"A clumsy, fat, left-handed, stuttering kid". Yes, I remember mentally reviewing that list of knocks I had given myself, while still in grade school. As concise as that list was, you would think that as a grade school "teacher's pet", I could find some concise answers to that list. Clumsy? Work on your coordination and strength. Fat? LOSE WEIG....sorry, lose weight; I tended to hear that solution from others at a loud level. Left-handed? Either have your hand dominance changed for you, or develop ambidexterity. Stuttering (another loud admonition)?? STOP STUTTERING!!

But life needed to go on. Life, food and learning needed nurturing. The food was especially captivating. Fried foods: so good. Fried chicken, fried oysters,  hamburgers, roast beef, roast pork, pork chops, shrimp, meat loaf, pizza, and spaghetti were among the more popular proteins. Corn, fried potatoes, mashed potatoes, rice and GRAVY, roasted potatoes, onion and celery, beans, peas, sweet potatoes, tomatoes, peppers, fried okra, lettuce and cucumbers were among the more traditional vegetables. But that omits any details of the snack calories available to me and my siblings: potato chips, cookies, crackers, candy, popcorn, gum, soft drinks (with peanuts poured inside), and fruit. In the final analysis, not that much different than the diet of most 1950's - 1960's kids, aspiring to be middle class. No one held a gun to my head during those years and said, "Eat that NOW", but I more often displayed my hearty gratitude for all that was served. All but spaghetti, because in grade school - I had been told by a sibling that spaghetti had worms in it.

There was garden produce harvested each year from our back yard, but not by me, if I could feign polio or some other low incidence malady. It was the act of growing up and being given a number of 'come to Jesus' talks, about learning how to cook and bake; learning how good it felt to contribute to the meal by picking, "snapping", cooking, serving, eating all those good morsels of vitamins, minerals, fiber and flavorful goodness - often accentuated by being cooked with butter and salt; but that was what was used for cooking at the time. Hindsight bias makes you feel so very smart, but it doesn't give you means to deny your history. "I got better", as the character in a noted "Monty Python" film noted. It took bare subsistence through my college career, and a few good friends who coached me through - when I moved to the Midwest US - selecting and preparing more fresh food. That trend would continue through transition to my non-single life.

I learned to ask for fresh, sustainable, lower-fat, lower-carbohydrate, properly-portioned food for my meals. One popular admonition about one's diet is as follows: Eat food. Not too much. Mostly plants. Thanks to journalist Michael Pollan and others - there were rules for healthy eating I could use.

Would I ever have reached a point where I could imagine being non-single, if I did not confront my fluency disorder? It started in the summer term between junior and senior undergraduate years, when I was enrolled in a general speech class for teacher training. My first speech completed, I was told to have an evaluation at the University speech clinic or - a teacher education track was not in my future. In that summer semester, with my first formal speech therapy program underway (there were no programs for SLP in my Mississippi district, during my school years), I grew up a lot. On a collision course with my growth as a fluent speaker, there were the Watergate hearings. There was my application to graduate school, soon to segue from a master's program in English to one in communicative disorders. And then, there was my trying out for a part in the Ionesco play "The Bald Soprano" as part of my treatment.

In each of these tracks of my impending adulthood, could I ask for what I wanted? We shall see.  

Be a Conscience

It's such a foreboding concept, conscience. Foreboding because we give the idea so much weighted respect. Conscience, after all, is one of our higher functions that make us truly human. It is one of the attributes of humanness that our moral mentors hold up through human history, as a "thou shalt" skill to acquire. Conscience is so much more than consciousness.  Where consciousness pertains to the baseline self-awareness of your internal state, conscience gives legs, voice and vision to your internal state. If consciousness is the voice of "I am", then conscience is the voice of  "Here I am, and - OMG! What did I just do?" Conscience may cause the ground under your professional life to go shaky, but with experience and good humor, you may keep your self-awareness balanced and have the best possible day in the workplace.

The profession needs consciences - individual clinicians, academics and advocates that actively bring their legs, voice and vision to keep their work focused, vital and memorable. When the work is focused, the clinician respects the work processes that have been proven optimal. Processes that do not allow the integration of the professional's skill, the needs of the person served, and the goals of the institution that sponsors the clinician - they get re-tuned to resonate with the vitality or life force of the clinician.  When you are prepared for the work day by being grounded with your own vitality, you can complete work tasks that can stand on their quality, and can be applied as memorable across patients and impairments.

As you become grounded in how your conscience, properly applied, can bring the most to your clinical or research activities, - also think about how the world external to your workplace can be guided by conscience. Does your person served, live in an environment that could contribute to their impairments? Is the support structure for the person the best that could be imagined? How do the person's communities, in concentric circles about this person's world, bring positive or negative energy to the person's quality of life? The clinician - researcher who exercises her/his conscience in the wider world; it is work that can be most rewarding - but perhaps not of the monetary variety.

Martin Luther King, Jr., is quoted as saying "There comes a time when one must take a position that is neither safe, nor politic, nor popular, but he must take it because conscience tells him it is right".

Be a Team Player

 

There may be no "I" in team, but there can be dog heads on a team. Since it's Super Bowl Week once again, and the 2017 post during Super Bowl week has been one of the most read int his blog's history  - here we go again. 

"Isn't that the way they say it goes" - you are barely comfortable in your own skin as a clinical professional, and then you are asked to be part of a group of professionals who, largely, don't do what you do! Aren't you subsuming your identity as an SLP to a group that demands more? 

In the right atmosphere, you can easily work alongside your interprofessional peers in a work team and set your standards high. You can energize your career, by helping persons served achieve outcomes outside the therapy room. More energy for your persons served and your workday, can bring the SLP many, many growth opportunities. 

Let this year's Super Bowl halftime entertainer tell you: 

I'm bringin' team work back (YEA)

Those PT's don't know how to state a fact (YEA)

I'll show them; writing won't bring heart attack (YEA)

....
Solo staff?
When you do treatment, you block wheat from chaff!

We need you for our team, for all, not half;
Your time is gold for patients, their behalf;...

....
Work with us (Be on our team)
Please help us (Be on our team)
DO MORE through us (Be on our team)

We'll do much more (with teamwork)
To keep our patients well; life's not a bore (with teamwork)
We tweak real life, so those we serve have life galore (with teamwork)
....
Work with us soon ( Go team!)
We'll see you at the meeting at full moon (Go team!)
To get your teamwork on....(Go team!)

 

Be a Good Citizen

I think there's a lot to do these days, just to keep this world a good place to be. We know that our country is in transformative times, when the underpinnings of what drives the civil society are all challenged. When the 24 hour news cycle, and the parallel, large bore, continually evolving information superhighway lanes keep pushing, bombarding, twisting, inundating our information processors between our ears, - human nature tells us to pull the covers up, as tightly as possible. "Why, why, why!? Leave me alone!" Why not just go through our everyday, only processing the breaking news we're forced to digest, because - it's all too much. "Too much!"

I mean, haven't we had it drilled into our procedural memories as SLP's, that productivity is one of the biggest feet on our daily gas pedal?!? Get those persons served, get your documentation done and PHEW! "That's all I can stands, I can't stands no more", in the immortal words of Popeye the Sailor. Though Popeye meant that it was time to right a wrong, in the case of the SLP clinician who is asked to get involved in the wider socio-economic-political world, that task may be a dike that even Hans Brinker couldn't plug. Why get involved in the bigger world, beyond the clinic or treatment room?

But ultimately, even the most hardened of us by the daily professional grind - we know that in order to make a significant difference in the bigger world, we have to carry the water of good citizenship ourselves.  Whether it is to  spread the news in your community about a clinic fundraiser; to buttonhole a legislator whose vote can decide a critical budgetary issue, keeping the lights on for your practice; to write an newspaper opinion essay on the work of your fellow professionals, and how cleanly our work dovetails with the goals of a body of government; to engage in dialogue with persons of all stripes across all the social media platforms, without concern for personal attack or truncation of your voice; or to perpetuate the values of the democratic republic that has supported the growth of our services, by being prepared then VOTING; - our taking a stand as a citizen of our society requires focus, requires energy that, at times, is very spare in all our lives, but - when it is done well, it makes all our lives more stable and more enriched and more - perfect. Novus ordo seclorum. 

If you see that being an advocate for an individual, a guerilla fighter for your profession, a lobbyist for an issue persons served face every day, a letter writer for your employer's cause, or a candidate for office in a professional association; - if you see that is for you, then - find a mentor to guide you through the webs and labyrinths of government, of public and private institutions; develop expertise or seek consultants to help you research information, as needed, for your interests; make a plan of short and long-term goals (we know how to do this!) for the projects that call for your energies; and then set out with glee and with purpose, to make the world a better place for persons served - and for the persons who serve them and their circles. Your entire skill set as an SLP will serve you well, as you grow in your role as a good citizen.

Be an entrepreneur

The reader overhears part of a motivational talk I give myself often, as I am leaving my car each morning to enter my job site: "This is a valuable service I provide. I don't go to work because it is where I am supposed to be, but it is work in which I believe. Today (the car door closes) I am going to make a lot of money for my employer, and help many people have a better quality of life. I am going to make deep inroads into my patients' needs. There may be scads of barriers in my way as I work on these goals, but - I will make progress on these goals!"

Sales. We don't go into the professions of audiology or speech-language pathology ostensibly to sell, but selling is a primary goal of what we attempt to do. In the beginnings of our careers, and even as we become mature and self-starting clinicians, we have to sell ourselves that we can do this. I didn't prepare the materials as well as I had hoped; - I stayed up too late; - I do NOT want to face my supervisor today; - and there are a bazillion other reasons not to go into work. But, let's assume the battlements at the job site are energetically rushed. Now we have to sell our work to our customers. Who's that?

Our customers are everyone from the person served and her/his circles of support; the referral sources; the support staffs around that person and behind the referral sources; the third-party payers that keep the human service system funded;  the educational system that prepares future professionals in the fields; - and the larger organizations that employ or otherwise empower our employment to serve persons. We close the sale for each of our customers when we fulfill our mission of service; when we work efficiently; when we work with sensitivity to the evolving needs of the person; when we demonstrate that our services contribute to a healthy bottom line; when we demonstrate that our services contribute to persons' increased health and wellness, not only for individuals but also for the population.

What helps close a sale for a clinician? First, realizing that you have a sales job to do for your customer. Tailoring then presenting your sales pitch. Depending on your customer, you have to make the pitch in a way that will get a clear response. Is it the response you want? Hone, polish, trim, refine and re-pitch the pitch until the deal is closed....if it can be closed. The cycle is repeated continuously throughout the work day, as a function of the customer's status. Constant deal-making. Constant marketing. The art of the deal is that deal-making is intrinsic to the clinical workday.  Who wins with your becoming an effective clinical entrepreneur? The person served wins. All your customers win. You win.