On the Trail of Evil with DICK DARING, Speech Therapist

On that fateful day, he facepalmed to gather his wits and calm himself, stopping the walk down this long hallway in the building he knew intimately, to scrape the slightly clammy flesh down his face and reset his thoughts for the afternoon. A toddler who had come to the clinic some weeks ago, to play games – so he thought – was on the floor, so Dick Daring was on the floor, too! In the process of living his best life with the Fisher – Price doll house, - the wellworn plastic device giving off a slight chemical odor - the toddler noticed that Dick had his back to the window letting in morning sunlight. Brilliant beams cast an outline around the speech therapist’s ear, bearing the signs of middle – aged hirsutism: hair sprigs no more than a ¼ inch from top to bottom of Dick’s outer ear, and the child couldn’t repress his need walk over to the therapist, and play in it with a finger. The mother was tickled – or was she mortified?? DICK WAS MORTIFIED. Make it stop, please! The therapist took a deep breath after resetting and then moved down the hall to his next case.

The walk down this hall seemed to take forever, though. Daring had worked here so long; used all the rooms to see all kinds of people, young and old; talked to his colleagues and managers in their offices over all kinds of cases; - that he tended to get lost in thought. The room on his right he was just passing had the barest remnants of a drywall patch on the far side. Dick had even been a student therapist here, and after a rather contentious meeting with a case supervisor about a report – put his then powerful fist through the clinic room wall, to be followed by a shriek of pain that would have awakened the dead! As Dick paused at that room’s door, he felt the offending hand throb a bit – and he then heard the clinic director calmly speaking with him, a few hours after the incident. Dick had been quickly escorted to the Student Health Center; his hand X-rayed, cleaned and wrapped with an Ace bandage, before he had been plopped in an office chair to learn his fate. “I looked over that report”, she said. “You were right with your calculations. Don’t ever do that again”, she said in a businesslike voice that belied her skill at managing people. Dick felt himself smiling as he moved on. One victory there.

Yes, Daring had been doing what he’s doing for what seemed like forever. He looked on the field of communication sciences and disorders – what the “man in the street” called speech therapy - so much differently than most of his fellow therapists, that he scarcely felt he could talk with them. He actually could talk with them! He could recite data recently published on a journal website, that explained informed consent for an “at – risk” swallowing therapy approach. He could demonstrate to a family member, or to the consumer with family in the treatment room, how blowing bubbles through straws of differing diameters was very similar to using the EMST (expiratory muscle strength training) technology, so popular now. Cost of a package of straws? As little as $3 USD for 100 straws. Cost of an EMST 75 or 150 training kit? $55 USD. Daring moved on down the hall and entered the next room, the case file in a clear plastic bin mounted next to the door.

This 25-year-old woman had initially “presented”, like she was an unlucky invertebrate pinned to a display board with those colored pins, as a case of severe hoarseness – conversational speech marred by sudden “pitch breaks” where her voice just cut out; she was often breathless, and she was increasingly frustrated at work – an educational co-operative – because persons calling her office had trouble understanding her. Today, she reported that her primary care physician had prescribed a proton pump inhibitor, a drug that stifles stomach acid production that seems to be refluxing up into her throat. She went on to say that she had promised to cut down on her beer consumption. After she demonstrated how much clearer her voice was becoming, reading 25 10 – word sentences without a pitch break, Daring scheduled her for a final visit next week, then left to move on to the next case.

“Dick,” a woman passed him by as he moved on. “Hello, Mary”, Darling replied without pausing in his brisk walk to the next case. Mary had been a fellow graduate student with him, but had moved on to becoming a staff supervisor, occasionally managing a case with Dick. There had been that time, he remembered, when he and Mary might have had something – until they had met one day at the materials center on the third floor. You had to check out a toy, or a test, or some specialized equipment to use It during a therapy session. Mary had just procured her toys for use with a child with cleft palate and turned to progress down the hall to the child’s therapy room. KAPOW! Daring, in his style, is barreling down the same hallway but in the opposite direction, lost in thought and carrying his FIFTH cup of strong black coffee without a lid! STUPID. They called it, when people gossiped about the event, the “eruption of Mount Mary”. She publicly forgave Daring for the incident, but on another level, their interactions were that brusque. Hello, move on. Daring opened the door to the next case he had been assigned today, a bit weary for the late afternoon.

Name: _____; Age: 55; Diagnosis: Severe aphasia after left hemisphere stroke, right hemiplegia. The patient held his right arm crooked against his chest, waiting seated behind the table and smiling at Daring, the case file in hand. “One time”, he greeted the veteran therapist with a smile. “Hi, Mr. ____”, Daring replied, resting his well – worn Fedora at the corner of the table. “How is your day today?”, the therapist asked. “One time!”, the client answered with a woeful sound to his voice. “Did you see the game last night?", Daring inquired, knowing that the client’s favorite team had won – and BAM! The patient SLAMMED his strong left hand on the table and exclaimed “ONE! TIME!!”, smiling broadly and then – showed that he could sing a bit of the team’s fight song when Daring started the song. He could actually sing the actual lyrics - !! “Applause!”, Daring cried out with a broad smile and clapped to celebrate the client’s performance. Laughter came from the client’s side of the table: “ONEEEEEEEEEEEE TIMEEEEEEEEEEE!”. Daring wrote down the client’s next scheduled date and time for another singing lesson, what was called in the literature “Melodic Intonation Therapy”.

Fedora back on his head with a slight tug to get the brim just right, Daring gently closed the door of the treatment room. On to the next case – Boy, this corridor seems extra long today.

SHE LAUGHED

That day, I walked past the aged dormitory building at my university – it had been converted about five years prior into a classroom, office and “clinic” building for the Speech and Hearing Center - I knew the person just stepping out of the clinic office door on the West side. My path was along the curb, and on the far side of the parking lot that served the Center building. My colleague took a few steps down the concrete ramp from that door, leaned over the railing at the edge and yelled at me: “HEY B______!” She was a classmate in my master’s level cohort, a little older than me but as driven by success as we all were. I yelled back, “Hey F____! “I even waved. I could tell that, even over the one hundred feet distance between us, she was perplexed by how I responded to her. “I SAID HEYYYYYYYYYY?!?!,” was my retort. What happened next was extremely embarrassing.

F____ and I had both been in a class about treating voice disorders. Usually, we heard in lectures, a speech clinic would get referrals from local doctors for voice evaluations. The people who came to evaluation clinic complained of sore throats, or dry throats, and drastic changes to their voices: tightness where before the voice had been full and resonant; or weak and barely heard when there was any noise in the room; or even a hole in the throat where the voice box had resided. With the evaluation, student speech therapists at our university would gather diagnostic information on how much control the client had over the pitches, the loudness, and the ability to use his/her voice in normal conversation and thereby meet daily needs. I had none of those typical voice problems, F____ had told me, when she led me into an evaluation room to do my own evaluation! She had gotten an order from my doctor for an evaluation!

Yes, F___ told me that she had heard, that day when we called out to each other, that I had poor breath control for my speech. She explained that, when I called out her name, I had so little energy from breath control ready that she could not hear the first word. I got out her name well, but I had to really push out the sound by straining my vocal cords. The sound of my voice, F____ said, was raspy at the end. “You should pronounce my name better than that, B____!” she said before a raucous laugh. Then F____ turned on her voice computer to start the analysis of my own voice quality.

The spectral analysis of my voice was marvelous for its time – the mid 1970’s. Everything is written in code now, with the analysis of a voice done in the Cloud. On that day we had to rely on hardware capability of the device connected to a desktop computer. We finally got an acceptable tracing of my saying the sentence, “The quick brown fox jumped over the lazy dog.” “What do you know?” said F____. “There’s your problem, B____. We have evidence you don’t have enough breath support until you get to the word ‘brown’! How about that!” She smiled broadly, then chortled a bit as she noticed my face – usually milk white – was now tomato red. “B___! Don’t do that!” she said, noticing my embarrassment. “Let’s fix this, OK?” She went on, her smile now soft and reassuring. I agreed, making the semblance of a muffled “OK.”

We started, F____ and I, to retrain my respiratory system so that I could adjust my airflow to every speaking situation I confronted. We used the spectral analyzer as an initial training point, and I read sentences she had selected for the training. I was to take a quick breath, into each corner of my mouth, before pronouncing the first word of the sentence. Since I had been a brass player for my high school orchestra, it was second nature to start a breath stream that way. It worked! Increasingly, I could be heard pronouncing each word of every training sentence clearly, and the spectral analysis captured it – all those squiggles were as fat and frolicking as 1970’s Elvis. I will survive!

F____ cautioned me that the work wasn’t done yet. Not at all, in real life you don’t carry around a small computer to give you instant feedback on how loud and clear your voice was. She then took me around our campus on a brisk Fall Day, to practice speaking to people in different places, doing different things, and in different kinds of listening conditions – quiet and noisy; good and horrible acoustic environments, where my voice might get lost in curtains, or bounce off concrete and end up in Georgia! “You have to depend on your ears, your eyes and your throat now, B____!” she said. “The feedback you get from your own body, and from the person you’re talking with, tells you if you got it right, OK?” F____ was brusque but reliable in treatment sessions. She was a mother outside the clinic, and her attitude she expressed to her kids was “Get with the program!” Another raucous laugh, before I followed her to find a speaking partner.

Needless to say, F____ got me speaking with enough volume for every situation I faced, through our treatment program and through the rest of our time as graduate students. Oh my God, we made it! She gave me a quick hug as we left the Auditorium on graduation day – her family was waiting. Then there was a tug on my gown sleeve, she pulled me close and whispered quickly in my ear – “Don’t screw it up, OK B____?” Flashing that smile, she peeled off quickly to exit with her husband and kids.

And she laughed!

Landmarks

He had always depended upon landmarks, places he could spot so he could find his way. There wasn’t anything really wrong with his sense of direction – he hadn’t been dropped on his head or played enough contact sports that his wiring for finding his way was messed up. He was just a visual guy. When there were family trips, he was the navigator and had that big – now ancient – Rand McNally map book on his lap. He would call out to his Dad, driving, “Turn here, Dad, now!”. His Dad had the quick retort always – “I see it, THANK YOU”. And so, it went. It was time now to walk to the train station. His day at the hospital was over, and there was no need to hurry home. He loved the 3 ½ miles on foot, largely because he didn’t have to drive with the melee of rush hour demons. It was time to walk.

Landmarks were just the best on this trip. From his building at 31st and Cottage Grove, he went west to the AME Church on King Drive, north along King past the mammoth McCormick Place and its well – placed curve west to Michigan. He felt the push coming now, as he then stepped briskly North on Michigan until the Art Institute of Chicago appeared. Left at the Lions and straight on until evening train! He knew instantly, as soon as he turned onto Jackson, that there would be a short hiatus before getting to the station. His smile was faint but unmistakable – and the cold twilight air was burnishing his cheeks. He knew he was geeking out now and someone will see him in mid – geek – but JEEZ, “The Dark Knight” was shot near here!

He stood on the LaSalle Street sidewalk and looked up so high, to scan the profile of the Board of Trade Building; up and up and up until he found the Ceres figure atop it. Goddess of agriculture, beckoning the farmers and the wheeler – dealers to come and trade. He took a few extra seconds to look Ceres over….and he liked what he saw. Sleek profile. An almost white skin tone. Eyes that saw through you, saw you. No one was going to put anything over on Ceres. She knew and she steered the eternal rhythms of the seasons. Before he left to complete his trek to the train, he felt the chill. It had come back, passed through him as a wafting smoke trail. For all but one of the last nine times he had taken this short side trip, the same chill was there. Smiling, he quickly turned west again on Jackson and made it to the train. It is important to get things together tonight, he thought, as the train doors popped open about an hour later. He did his best to miss the young woman exiting the car next to him. Oops, sorry! He croaked out as he slightly jostled her, blushing as he hurried to his car. Tomorrow was Halloween! Got to get everything ready! As he did every evening, he took everything from his pockets, soon as he was home, and placed every personal item in a large Santa – themed candy dish.

Halloween morning seemed no different than most other cold October mornings, back at the Office. He had gotten there before 8, so that he could put up the few decorations the boss would allow in the office. His bright orange jump suit with the “Cook County Jail” letters big and bold could be seen from street level along 31st Street. I’d better not get close to the window, he thought with a chuckle escaping him. People will think I’ve done a breakout! The chill hit him then – HIT HIM HERE!? That same chill he felt when seeing HER? A panicked cry, then a startle and he looked about to find the – OMG!

She was here – CERES! Sleek with the piercing eyes. She had a porcelain mask over her face, but her eyes betrayed her. Gawlllll – yes, I was transfixed, but my body betrayed my fear! “Uh, Uh, hel – hello” She tossed her head a bit, the long blonde locks that a Goddess of the land might have, they danced over her shoulders. Her immaculate costume scarcely rustled, when she lifted her left hand to flash well – groomed fingers in a menacing gesture. Yes I did, I watched those fingers with trepidation – was she going to scratch me?? I watched her left, and didn’t see at all the pocket pistol that smoothly appeared in her RIGHT.

“You’re a very clumsy guy,” She said with a flat tone as she lifted the Staccato CS pistol. “Cl - clum - clumsy??” “Bumping into me on the train – I could have fallen under the train!!” The chill hit him again – just before BEFORE THE GUN WENT OFF! Her scream, the gun!!

It was an hour before I was able to sit up – patting my sides and touching my head, in an utter panic all over. Other than the soft corners of my extremities a little tender, from the impact of my fall – no blood! No entry wounds or exit wounds! I pressed my palms into my forehead, stroking them down until I removed them from my chin. Then a quick double take, quadruple take – where’d she go? Ceres?? Where’d she go? No evidence that she had been there – and no bullet holes, anywhere! I had to find out - quickly springing to my feet, I then spotted, on the full length mirror, a message written to me IN LIPSTICK. It read, “TRICK OR TREAT!....then a capsule description of what had happened over the last hour and a half. Ceres knew: I’m a visual guy.

Not a Sexy Life

Ahhh, that feels good. SURYA NAMASKAR; it’s the sun salutation. First comes the mountain. Breathe in cool morning mist. Reach up and greet Sol. Smile as you take in the warm vapor. The fold you make of yourself keeps – Ahhh breathe – keeps you floppy. Flow up, HELLO AGAIN; your breathing rhythm paces you. You become a stalwart plank, instilled with rigid air flow. Then skulk near the ground, plank, almost a dog, breathe dog – The dog rears up, a bowel – filling deep breath. The dog bends down, and air bends still. And, near the end, you slide up with a breathing. ANOTHER FLOPPY FOLD? Your slow breath calms you. And once again, wave upward towards your next breath. Before we reach the mountain’s top, ahhhhhhhhhhhh.

Wow, that felt good. I’m relaxed now for my morning shower. Before I started my pre – shower yoga routine, I was feeling very anxious about falling. It’s that simple. I’m old and I’m afraid of falling. But I’m lucky now - checking myself out in the mirror before I step over the tub rim – I’m lucky, because I’ve moved into a place with lots of safety precautions. A fall won’t be easy here. Why am I so worried about falling at my age? Kids don’t seem to linger in torment after a fall; I envy that. My son had his first formal photo made, soon after he had started walking. His mother was NOT pleased that, immediately before we were to drive to the portrait studio, he earned his first forehead booboo - his forehead kissed the sidewalk near the car! But after a few minutes of whimpering and first aid, off we went to be immortalized in film. Off I go: my steps inside my shower are flat – footed, steps that my wife called the “Sanibel Shuffle”. She said, you learn when vacationing in Gulfside Florida, to shuffle your feet over beach sand to go into the water. It helps you avoid stepping on horseshoe crabs, and inside the shower I turn to reach the soap. I shuffle slowly and carefully, to avoid stepping on the inner shower liner.

My ace – in – the – hole during shower times are the three – 3! – grab bars, one on each wall of the enclosure where I was scrubbing vigorously. Feet Sanibel flat; breathing slow and even; talking to myself quietly, because the acoustics are so good. Feet flat, knees slightly bent, posture erect, my hands working from arms to chest to abdomen to legs to feet. I was reminded by a TV comic the other night that white people don’t wash their legs and feet, so here goes the scrub while I hold a grab bar for balance. Between the toes Our old apartment had two grab bars, put in by my brother – in – law when his mother was coming to live with us. Mother – in – law was newly admitted to hospice. A hospice nurse was on duty the evening when Betty came to live with us. Betty didn’t make it through that first night. The grab bars remained.

I rinse off my torso and limbs, again holding to one grab bar. Lathered hands scrub my face and ears and scalp bordering my shrinking hairline. The moderate pressure I used to rinse my forehead made it impossible to miss the numb spot along my left brow. The warm spray on that forehead spot felt good. I reminded myself with a whisper to slightly arch my back, my neck straight. My memory was strong for that day. Could I have predicted what happened? Had I been at risk? While I was in the hospital, I ran through a list of risk factors. Was I – • Over 65? Yeah, I couldn’t do anything about that. • Carrying more than 3 diagnoses? Only hypertension. • Had I fallen in the last 3 months? NO. • Was I incontinent? NO. • Having a vision problem? Not at all. • Having problems moving? No. • Exposed to environmental toxins? No. • Taking at least 4 medications? No, only 1. • In pain? Not at all.

I had four appointments that day, as well as a physical exam with my primary doctor. In hindsight, a stupid bit of scheduling for the doctor visit – not seeing the doctor until 1 pm, and I had to go without food or drink till then. After I was done with the appointment and the blood draw, I grabbed something to eat and resumed my schedule. The third patient seen, a cup of coffee for some energy, and off to the fourth. Now scrubbing my hair; reaching down to the tub corner for the shampoo bottle, lifting my hand that held the dollop of shampoo, then conditioner in turn, and keeping my feet flat, my knees bent, my neck erect through the wash and the rinse. Then they found me. They found me, the paramedics, lying on the pavement in front of my fourth and final assignment – passed out in front of a senior living community. I really loved that sweater the paramedics had to cut off me, but it was bloody from the gash on my left forehead. A bleed on the left side of my brain was another mark on my safety record – luckily it had disappeared within two days, and I could go home. Now I’m home, practicing moving slowly, thinking slowly, so I don’t fall again. With a light grip on the back grab bar, I step out slowly, planting my foot firmly on the floor, knee bent to transfer my center of gravity forward. I’m moving forward. Toweling off before the mirror, I know I have to count my blessings. My background in healthcare helped me understand that, if I pay attention to my posture; how I use the balance sensory nerves in my ankles, my hips, my neck and my ears; how to move in a chaotic space; and how to keep my muscles, joints and my spirit in good shape, I’ll get through every day as best I can. Slow thinking, slow moving; it’s not that sexy a life, but a safer one.

Alzheimer's Prevention

My late wife and I had often shared an inside joke. Often the springboard of the joke was that she asked, why are you doing it THAT WAY? We lived in suburban Chicago, where often a first - tier conversation at a gathering would begin with: "How'd you come?". The culture will recognize this clip from 'Saturday Night Live' as another version of this query I often heard at family parties.

See now my wife and I driving to that same family party, and she notices that I'm taking a route that is not the typical path we had taken to that family member's house. Again, she asks me WHY ARE YOU GOING THAT WAY? I smiled at her and replied almost instantly, not even flinching in advance for the controlling head slap some husbands might get - "Alzheimer's Prevention".

With time, my wife would beat me to the punch. She'd see me or hear me talking about a job that I had planned to do about the house, at my job, or in the garden. She would comment, with an Irish upward lilt in her voice after hearing my innovative ideas for the job in question, "Alzheimer's Prevention???". She was so smart! Having shared the use of compensatory cognitive strategies with gobs of people who'd been diagnosed with a cognitive impairment, I've adopted their use for myself, much of the time. After all, one day I might be across the table from my own speech - language pathologist.

Just as the medical expert attests in the AMA video cited above, lifestyle strategies that may help prevent cardiovascular disease and cancer will also be great preventive tools in one's toolbox against dementias. Diet, exercise, weight control, medical management of 'the three bloods' (pressure, cholesterol, sugar), sleep, and tobacco exposure are largely within our control with proper guidance. When it comes to cognitive strategies, the often cited but barely attributed 'WRAP' strategy is a sufficient anchor for most of us. W = Write down what you want to remember. R = Recall or practice a Routine. A = form an Association of what you need to remember, with another memory that will easily cue your recall. P = Picture your item to remember.

I will often write short notes on a Post - It sheet - often a sheet printed in a bright color - then I leave the sticky page on my desk the night prior, so that I might get the cue to accomplish something that next morning. My cognitive routine that I boasted of frequently to home health patients, entailed my placing all my personal items carried in pockets during the day, in the exact same area in my home each night. Associations are the easiest strategy for me to use; it's just seemingly how my brain is tuned. For example, when I see a photo of Marina Towers in Chicago, I think of 'The Bob Newhart Show' TV series, since the series opening always showed the buildings. When the Denzel Washington character in the new film 'Highest and Lowest' approached an apartment door with the sign 'A24' on it, I immediately recognized it as the name of the movie production company behind the film. Picturing? That I often rely upon, when I am driving distances and relying on landmarks to locate a turn or gauge a distance to reach home.

The strategies extend from simple recalling of everyday names, facts, object positions, and daily events. "Alzheimer's Prevention" means as well, performing a physical task differently at different times. That way, I force myself to focus carefully, move slowly, and be mindful of steps in a sequence of actions. This might include taking a walk about a familiar route, but reversing the direction of travel on random days. Another: bathing in a tub on one day, then showering on another. Young readers of this blog who feel puzzled at the advantages of doing such a simple task in different ways - age about 50 years. You'll see. How'd you come?

We're Just Not Sexy Enough

I have this rant fairly regularly. What public presence does my profession, speech - language pathology (SLP), have? What do people know about what we do, when I tell them what I do? Is our story told well in literature, or in pop culture, news, film, stage, music, or through ANY VENUE? I'll spare you a review of my previous posts on the subject, but my assessment of our plight is dire. It seems that we're just not sexy enough to have our story told. Is being un-sexy a detriment to doing our job? Will we remain the best - kept secret in town, until a doctor's referral drops? The hard reality of clinical practice in SLP includes: a wide variation in the rate of referrals, especially from doctors; referrals rescinded when patients refuse services,even though communication or swallowing may be severely impaired; uneven education by physicians about what SLP does; a dearth of marketing of SLP services to referral sources, by the persons who pay us and supervise us; limitations in non - productive time by SLP practitioners to market themselves; and little or no budgeting within rehabilitation departments for SLP consumable supplies and materials. SEXY? What about survival? Let's see where the sexy train goes off the track.

The medical comedy "Scrubs" featured a recurring character, a soldier being treated for effects of a brain injury in Iraq. SOME of the effects! You see a physical therapist working with the patient on his handwriting, commenting that she had acquired an "occupational therapy pencil" to conduct the treatment. The soldier also presented with memory breakdowns, which led to some opportunities for jokes, not for cognitive treatment.

The Netflix streaming platform currently features the Japanese series "The 19th Medical Chart", a popular series featuring a character who would be called a family practice physician. When the featured physician was consulted on a case of hypopharyngeal cancer, I immediately expected that rehabilitative efforts would be a serious component of this story. Not in the least - the surgery on this lesion was the outcome. Vocal rehabilitation? We'll see what happens.

And wouldn't you know - even physical therapists can lose their sexy edge! The FOX/Netflix series "The Resident", has featured more than one patient character who when offered rehabilitation after orthopedic surgery, complained that therapy would take so long! The surgeon and his internist colleagues shimmer with sexiness, once again.

So my rants about SLP's visibility, its sexiness, always end up with this realization. We may be consultants who may rarely be used, but we're used because, as Dr. James Coyle reminds us, the doctors can't do what we can do. We help our consumers find themselves, and that journey is only as long as it takes.

I Won't Know What You Do

The day was almost over for me. I had successfully seen two people in my area, and had successfully led them through some activities. I was running now on very little energy. There was a saving grace in this being my last visit of the day, because this consumer had some different needs than the rest of my caseload. She had had a cardiac episode that took her to the hospital, where she underwent a cardiac bypass graft (CABG, or by those in the know, "cabbage"). Your question might be now, how do problems with your heart affect your speech? Answering that question required more than a few minutes, but I felt it was critical for our first visit to establish with the consumer - why I was the expert. I needed her buy - in for the evaluation procedures I had planned for her. If she didn't know what I was doing, why would she want to burn energy and do the work to get better!

She soon did say she understood that the major nerve, called the vagus ("wandering") or tenth cranial nerve, feeds both her heart and her larynx, or voice box. This connection often shows up in the videofluoroscopy suite, when a consumer presents for the swallowing x - ray with the complaint of a dry cough - and the sensation that something is lodged in his throat. Often, the person has a history of cardiac problems. Not only can the primary medical concern affect the larynx's function, but the support the consumer received to breathe during the surgery, would show up as a dry cough. Hmmmm....my listening to her voice told me that there was intermittently, less power in her sound with pitch "breaks", like a sputtering short - circuit in the stream of conversation.

I was thrilled to see last week the new Netflix comedy special by Vir Das; not for the misfortune he had to overcome, but that he had a treatment technique suggested for him that this lady used as well. He cut great comedic hay from this, but it is simple, it's real-world, and it often helps! You'll have to see the special to learn the technique. I told my patient, who had a quizzical face on when I handed her the specialized equipment, "OK, I've shown you how to do this. You gave it a try, and you showed me that YOU know how to do it. When I'm not here, I've asked you to practice using it in your exercise, but - I won't know what you do! I can only hope that you'll try it and notice if it gets easier - that might tell you, speaking longer is getting easier!".

At the end of the special, Vir Das showed what he had learned. My patient did as well - the credit not due to me, but in the faith she had shown, that she would get better.

Do You Have Primary Prevention Products? w/ M. Elwer

Not long ago, I walked through what could be considered a speech clinic of the near future.

You might imagine sleek exam rooms outfitted with high-powered flexible endoscopes capable of visualizing oral, laryngeal, and pharyngeal structures in stunning detail. Perhaps you picture the latest tablets and smartphones paired with high-fidelity digital audio systems, ready to reproduce speech output with crystal clarity. And yes, today’s communication sciences and disorders (CSD) professionals are rapidly updating practice models, with major shifts in third-party reimbursement policies unfolding even as this post is written. But instead of being packed with cutting-edge tech, the clinic I visited had changed in a different — yet equally profound — way. On its shelves were not just diagnostic tools or therapy devices, but something often overlooked in our field: primary prevention products. The inclusion of prevention activities in clinical practice represents both something new and something deeply rooted. But what does prevention really mean for a CSD professional? How futuristic is it to position prevention as a product line? And can most practices absorb prevention into their existing business models?

A Slow-Building Revolution In 1987, the American Speech-Language-Hearing Association (ASHA) released a position paper advocating for the prevention of disorders related to communication, cognition, and swallowing. This wasn’t an immediate call to action — more like the birth of a slow-rolling snowball, steadily gaining size and momentum. To many clinicians, prevention may feel like a radical departure from traditional models. The reaction often goes something like: “Wait — not only do I help people improve after a disorder develops, now I have to work to prevent them from needing me at all?” The answer, in short, is: yes. But paradoxically, incorporating prevention can actually drive more people to your door. In the short term, yes, it may reduce some individuals’ need for intensive treatment. In the long term, however, it increases your community visibility, builds trust, and ultimately expands your reach.

Understanding Primary Prevention Primary prevention aims to reduce or eliminate the conditions that can lead to a communication disorder before any symptoms arise. This can be done in two main ways: • Altering a person’s susceptibility (e.g., improving vocal stamina so someone is less affected by noisy work environments) • Reducing exposure to risk (e.g., modifying a work schedule to give the voice time to rest) For many CSD professionals, this concept feels the most foreign — perhaps because primary prevention isn’t reimbursed like diagnostic testing or treatment. And it doesn’t always look like “therapy.” It often looks like selling or teaching tools, activities, or techniques to individuals who don’t yet have impairments. Can we teach healthy people how to stay that way? Can we stock and sell low-cost wellness products? Can we handle the sales tax? Yes, we can. But we must step out of our comfort zones as clinicians to do so. The return on investment? A stronger community presence, a broader impact, and a more sustainable professional model. ⸻ So What Is the Stuff of Primary Prevention? In this future-forward clinic, here’s what I saw on the prevention shelves: I. Oral-Motor / Motor Speech • Kazoobie Kazoo – $2 • Hohner Beginner Harmonica – $8.50 II. Fluency • Mouth Sounds by Fred Newman – $10 • The Speech Choir by Marjorie Gullan – $1 (used) III. Voice • C.D. Bigelow Elixir White/Green Hair & Body Wash – $10 • 1 gallon distilled water – $1 IV. Swallowing • Ziploc kit with Life Savers & mint waxed dental floss – $5 • Ziploc kit with 12 sterile tongue depressors – $5 V. Cognition • Radius ergonomic garden trowel – $10 • GAMES magazine, single issue – $5 VI. Speech & Language • The New Moosewood Cookbook by Mollie Katzen – $10 • Walk Off Weight with Your Pedometer by Jan Small – $10 Note: Product mentions are coincidental and non-sponsored. These items were selected for their low cost, broad community availability, and potential to support wellness through primary prevention. ⸻ The Clinic Experience In this imagined clinic, the prevention section has its own street-level entrance, keeping the flow of wellness consumers distinct from tertiary care patients. Adjacent to the retail area is a video viewing room with several devices for product demonstrations. Nearby racks offer literature from local wellness resources — classes, community events, and support networks. The aim? To immerse the customer in a holistic health-promoting environment. ⸻ Back to the Questions Let’s revisit the original prompts: • How do we do primary prevention in CSD? • What is the stuff of it? • What are the outcomes we want? We do primary prevention by teaching, training, referring, marketing, selling, cooperating, and participating. We bring healthy individuals into our sphere not just to diagnose, but to keep them healthy enough that diagnosis never becomes necessary. We collaborate across community sectors — with educators, fitness instructors, faith leaders, performers, and health coaches — to support our prevention mission. Outcome measurement may be simple: improvements in health literacy and patient activation, such as those measured by the Patient Activation Measure (PAM) developed by Hibbard and colleagues. The ultimate outcome? Lower long-term healthcare costs, higher function, and more empowered communities. The story of primary prevention in our field is still being written. As we walk through this near-future clinic, we must ask ourselves: What do we see on the shelves? What kind of professionals are we becoming? Next stop: the secondary prevention wing.

Launching Lifesavers w/ M. Elwer

Let’s be honest: as candies go, Lifesavers seem innocuous enough. A sugary halo of nostalgia, lightweight in both texture and guilt. Five calories apiece, maybe. Small enough to forget—unless you’re a speech-language pathologist trying to teach a man how to cough again. This was no ordinary coughing session. This was Mr. H., a retired jazz pianist with bulbar-onset ALS and the wry humor of someone who’s played too many smoke-filled clubs to take much seriously anymore—including me. And yet, there we were, him eyeing me suspiciously as I held out a single cherry Lifesaver and said, “Put this in your mouth. Don’t chew it. Now blow it across the room.” “Blow it?” he croaked, eyebrows rising so high they almost met his hairline. “Lady, are you trying to kill me or save me?”

Honestly, I didn’t know the answer to that in the moment. It was absurd on the surface: giving hard candy to a person with a compromised swallow? In most clinical scenarios, this would have been malpractice, if not suicide. But desperation and science often meet in strange places—and this was one of them. Research had emerged—Plowman and colleagues again—suggesting that expiratory muscle strength training (EMST) could preserve, and in some cases even improve, cough and swallow function in early-stage ALS. The concept wasn’t new, but its application was still uncharted territory. We weren’t chasing miracles—we were chasing milliseconds of preserved function. And sometimes, milliseconds matter. So yes, we launched Lifesavers. I set up a towel runway on the tile floor, marked by neon tape. I positioned Mr. H. comfortably in his recliner—spine neutral, head resting back, feet planted wide like he was bracing to play a power chord. The goal wasn’t candy ejection, per se—it was abdominal engagement. Diaphragm activation. The art of a well-supported cough disguised as something playful, even ridiculous.

“Take a breath into your belly,” I said, miming the expansion with my own hands. “Now—BLOW HARD. Send it flying. You can’t let this candy beat you.” He rolled his eyes. Then he blew. It went about six inches. We laughed. He cursed. We tried again. By the sixth attempt, the Lifesaver hit the tape. By the ninth, it cleared it. On the tenth? It ricocheted off the coffee table leg like a tiny red puck, earning a fist pump and a raspy cheer from Mr. H. And then—something extraordinary. As I leaned down to retrieve the candy, I heard him say, almost clearly: “Don’t waste a good one. That was cherry.” It was the first spontaneous, intelligible sentence his wife had heard in weeks. You can’t always measure success in meters or milliliters. Sometimes, it’s measured in shared laughter, a candy skimming across the floor, or a whispered flavor preference breaking through the fog of disease. Sometimes, what looks like nonsense is the deepest kind of therapy. And sometimes—just sometimes—spitting candy can help someone reclaim their voice.

A Day in the Clinical Life

The time: it could be an hour from now, or it could have occurred twenty years ago. The place: Just outside my patient's space. She might be in a clinic treatment room, or it might be her apartment or home. I enter - "Good morning!"

"Thank you for letting me visit with you today. Your doctor asked me to visit with you, after you returned home from the hospital. Who is the doctor that ordered my visit? It was Dr. _____! You remember her, good! Did you work with a speech therapist in the hospital? OK - what I want to do is to help track your recovery from your condition. May we do that? Thank you. Do you think your ability for _____ has changed, since this all started? Tell me what you can".

"Thank you for the compliment. My mother used to say I was a nice person. I kidded with her in return, now I'll never get a date! But I think it helps me help others. Did your parents or your teachers, or other adults want you to be that way?....OK. I've enjoyed our conversation, all of it, and our conversation has given me some clues as to what you're dealing with - Can we now do something now, that's a specialized way of observing how people communicate? WE CAN? Oh, thank you. I'll explain each part of this, but please ask any questions if they come up".... ....and so it goes. After all the assessment is done, and I explain what I see, and get feedback from her, I work to "close the sale". That's a component of what we do, speech - language pathologists. Improved skills are our widgets, our EV's, and our commodity futures. Our product, when it is sold with clarity, honesty, compassion and commitment; - it's the best. We only want to help you connect.

Time Out: The Importance of the Handoff (revised from 2/5/2017) w/ M. Elwer

The whistle is blowing today—not just on the football field, but on our current blog series about becoming a better SLP. Time out! We’re stepping off the sideline to examine something that happens every day in speech-language pathology practices: the handoff. Just like in football, a good handoff can keep the momentum going. A bad one? It can result in a fumble. In our field, a handoff happens when another clinician steps in to cover your caseload—maybe because you’re out sick or on vacation. And just like a quarterback handing off the ball, the success of that session depends heavily on how well you’ve prepared your substitute to carry the play forward.

Of course, the treatment plan is already in place. It outlines the goals and objectives, both short- and long-term. But treatment plans don’t carry the full picture. As the SLP of record, you’ve likely built a therapeutic relationship, developed trust, and discovered which activities truly click with the person you’re serving. You’ve gathered a set of materials and approaches tailored to that individual. The covering clinician doesn’t have that advantage—and shouldn’t be expected to start from scratch. Why not? Because they haven’t had time to build that same rapport.

The covering SLP might ask questions like, “How do you feel about your speech therapy progress?” or “Which activities have helped you the most?” But if the client doesn’t remember or can’t communicate that effectively—and you haven’t left clear guidance—then the clinician is left guessing. At that point, it’s tempting to reach for a generic activity that’s worked with others who share the same diagnosis. But here’s the problem: a diagnosis doesn’t tell the whole story. What works for someone with aphasia might not work for this person with aphasia. Predictability drops sharply when we remove the individual from the equation. That’s why a good handoff includes just a little extra effort. A note like this can go a long way:

“Reminisce with her about family days. Use the photo album by her bed. Point out family members and ask about what’s happening in the pictures. When she talks about her family, her fluency improves dramatically.” Sharing that kind of detail takes maybe sixty seconds—but it could make the difference between a forgettable session and a meaningful, goal-driven one. So the next time you’re handing off a caseload, remember: it’s not just a plan of care—it’s a play in progress. Make the pass count.

My Swallowing Is My Business (revised from 11/6/14) with the good taste of M. Elwer

This post offers a glimpse into what I call “organic SLP” — speech-language pathology that grows from real human experience and education. The goal? Empowering patients to understand their own bodies and take action to prevent disability whenever possible. One of the most effective ways to do that is by teaching the basics of normal function. This handout, originally created for an actual patient, is just one example. As always, your feedback is welcome!

⸻ Most of us don’t think about swallowing — and why would we? I certainly didn’t, at least not until it became part of my clinical focus. The truth is, I started swallowing long before I ever had a conscious thought. Scientists have found that human fetuses begin swallowing around 15–16 weeks of gestation. I developed my first taste preferences in the womb. After birth, I was fed by others and eventually learned to feed myself, developing the skills to get food into my mouth and down the hatch.

As a child, swallowing was something I could do in just about any position. I ate sitting upright, of course — but also lying flat on the couch, hanging upside down, and even mid-spin on a carnival ride. I did it because I could. I didn’t think much about posture or process. As I got older, however, I began to notice that swallowing worked more easily — more efficiently — when I was upright. Gravity helped, coordination improved, and things just felt smoother. Swallowing is both voluntary and involuntary. Some muscles I control intentionally — like those involved in chewing and moving food with my tongue. Others work automatically, governed by brain regions that don’t require conscious effort. These two systems — voluntary and automatic — work in seamless cooperation, allowing me to swallow thousands of times a day without giving it a second thought. Over the course of my life, swallowing has become a set of deeply ingrained habits — a finely tuned sequence of motor memory. Here’s what it looks like for me:

I pick up food with my fingers or a utensil. For liquids, I use a spoon, cup, or straw to bring the fluid to my lips. I hold the food or liquid on my tongue, shape it into something manageable, and either chew or compress it until it forms a cohesive, slippery mass (known as a bolus). I then use my tongue to squeeze the bolus to the back of my mouth. That’s the point where control starts to shift — when my swallow is “triggered” and the automatic part takes over. The bolus is propelled into my throat. My larynx (voice box) lifts, the airway is protected, and a valve to the esophagus opens. Once the material enters the esophagus, it’s carried to the stomach by rhythmic waves of muscle contractions. That, in short, is my swallow. And yes — my swallowing is my business. It matters to me because eating is about more than nutrition. I eat to live. I eat for comfort. I eat to connect with others. That’s why I teach patients to care about their swallowing, too. Because when we understand what our bodies are doing — and how to support those processes — we can protect our quality of life. My body. My business. My swallow.