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. 

The Rent You Pay

"Service to Others Is the Rent You Pay, for your Room Here on Earth" - Muhammad Ali

I untangle tongues 'cause I like it!
I like the breakdown into parts -
You work on this process and that one;
You strive for more Science than Arts

So when my patient's all better
I go to the data to see:
Does the trend refer just to blind chance
Or is there authenticity?

Authentic is how I would want me;
So much in the moment, that we -
My patient and I - we're sympatico -
We did make a difference; OUI OUI!

We each have served each other,
The helper and the helped;
Some magic was done by the helper
And her humanity was further whelped

When you serve others, you're lightened;
Dross burdens can all fall away
You float, then you sting;
That venom will linger
Someone will stand taller today.

RIP to the Champ.

Like butter

(I hope to high Hades that I can beat back the noise of the staff, who say my patient can't eat. We had known she was picky about her food, from before the time she had gone to the hospital. Now, she still shows little drive to eat. There are things that can be done. Sometimes everyone is a critic, but - that's why they pay you the big buckaroos.)

The patient was asleep at her table in the dining area, during the lunch hour. She was presented with a tray of pureed food, and fed bites of food and cup sips of liquid. The scoops of each item appeared to dry instantly after being served, so pats of margarine were stirred into each colored oval to add flavor, and some viscosity. The patient was instructed to take each bite and "swallow hard".

(Good gravy Gertrude - one, two and now THREE staff are stopping to watch me feed her! Well, that's good....the tsp laden with the food - mashed potato used as glue for little bits of the other, then held for the patient to see what is there - then she is asked "ready?" before each presentation: THERE YOU GO, good good - though I have to wait 1,2,3 or even 4 seconds before she closes her mouth to pull off the food, but THERE - some downward pressure on her tongue elicits that movement much more easily....)

Gradually, there is a rhythm. The patient wakes up and - especially after being given the initial bite of ice cream - opens her mouth more and more demonstrably, until she is responding to the visual cue in real time to take 90% of the bites and sips, without a verbal prompt.

(Now there's the dietician! Yes, it took some warmup to get her participation at this level, but she did it. Now, I hope the staff will see she CAN be fed....keep the viscosity at appropriate levels; assure flavor; keep the patient engaged in the process w/ coaching; move at a speed at which the patient can function; and - be positive! Find a way).

The noon meal flowed like butter, until - it was done.

Secondary prevention products

I like this topic: secondary prevention, known to us rank and file clinicians as "screening", is among our best marketing tools for the field. The places I've been, and the things I've seen while screening people of all ages, for communication and swallowing needs: kindergarten and first grade gymnasiums; senior center meeting rooms; high school study halls; supermarket alcoves; - and a wide variation of other sites and situations that allow meet and greet, Q&A, test and counsel and refer, and sell, sell, sell what we do - so well. Is this what is done in other fields when there is effective secondary prevention?

In the speech, language and hearing clinic of the near future, first described in an 11/28/12 post for this blog, prevention is not solely a few lines in a position statement of a professional group, - it is also an actual product line that has potential to bring in substantial revenue to the clinic. The secondary prevention product line for this clinic will operate along three fronts (Ontario: Institute for Work and Health, 2015):

* detecting and treating disease/injury as early as possible;
* encouraging personal strategies for prevention of recurrence of the condition;
* implementing programs to return people to return to their original health and function;

As primary prevention encourages SLP professionals to get out of the therapy room, so goes secondary prevention. To help persons in the community come forward when they suspect they may have a communication or swallowing problem, the secondary prevention staff have to promote scheduled screening events: in print and electronic media; through speaking events to social organizations, by distribution of educational material in many forms, and in making the screening venue accessible, attractive, and friendly to the participants.

At screening events, there need be a commitment for proactive time management, efficient scheduling, current science applied to the measurement tools being used, sufficient time spent with the participant who needs education and counseling, an easily followed procedure for accessing other levels of the human service system, and reliable and valid data management systems. Above and beyond all the meticulous care a screening manager will use, - working a screening clinic can be fun! You explain what we do for the general public, in terms they can understand. You encourage buy in for the process of taking care of your skills for communication and swallowing. You liaison with the human service system, as a personal  and system advocate. But, but but beyond that:

You may help identify problems a person may have, and you may help the person identify resources they can access to improve their wellness. Are there services/ interventions you offer,  that will help the participants resume their usual activity, without enrolling in formal 'therapy'? If these services stop short of working with clinical impairments, but address real world needs people have in these areas (e.g. the picky eater, or an accent that seems to limit the person's occupational success)
 - how robust are these services you provide? Your screening services can provide rich data along more than one domain. Getting more invilved in the development of prevention as a product in your line, will help answer these wuestions. Consider secondary prevention as an essential tool for your SLP practice.

We Named the Salad

" We're fortunate that our patients wanted to get these plants started in the dead of winter - relatively speaking. It's now May, and our first crop of salad greens is ready for harvest! OK, now: let's review what is going to happen in the group today. Ellen?"
"John is going to harvest enough Swiss chard for our first salad - but, how much is that?"
"Let's see - we're not cooking it but dressing it, so - there are six of us working, patients and trainers, and we'll probably eat 1 tablespoon each (gotta be realistic!) so - 6 tablespoons!" But, can John see it?"
"Sure! I marked the boundary around the chard bed with red colored duct tape; he can't help but zero in on it."

John's treatment plan for 5/7/16: John will cut 6 Swiss chard plants within his line of vision, with no more than moderate verbal and gestural cueing, and with 83% (accurate-delayed) accuracy. 

"OK - good plan; his field of vision is better but this will help him focus on the job. Becky - will Mary Anne have any difficulty pulling the radishes?"
"If I am not there for the entire time she can pick enough enough radishes, then she may go on a tangent and rip out a red light bulb from the night lights!"

Mary Anne's treatment plan for 5/7/16: Mary Anne will pull 6 radishes from the raised bed, with constant verbal, gestural and tactile cues, and with 60% (repeat prompt) accuracy. 

"OK then! I think you know what to do. And I am working with Celeste today; her job is to follow John and Mary Anne, and check that they have completed their jobs before we all head to the kitchen".

Celeste's treatment plan for 5/7/16: Celeste will record the performance of both John and Mary Anne on their garden assignments, and report to both Ellen and Becky on their execution of the plans - with occasional cues, and with 93% accuracy. 

"But, but - that means we have only chard and radishes for the salad?!?!?! BLecccchhhhhh....; BORING".
"OOPS"
"We'd better then go for more: I don't cook that often. How about, then....after John gets the chard, he can also cut some arugula. Then Mary Anne can....get some shears and cut some butter lettuce. That should be ready, too - right, Becky?"
"Right! And I will keep an eye on Mary Anne using shears; maybe, tell her she has only 15 cuts allotted from these shears today!"
"I agree. There is a head of iceberg lettuce from the grocery in our refrigerator; we can use it to add the "crunch" that many salad eaters tend to crave. Also, can both of your clients swallow nuts without problems?"
"Yes"
"O Yes!"
"Great. The creamy dressing should help hold everything together in a good bite to swallow.  There's crunch, and there's sweetness. There's pepper in the arugula, and there's pepper and crunch in the radish. Anything left?"
"No, Doris".
"Let's go".

The call came in....

I was working the day watch out of swallowing division, and was about to go out on a call when the desk sergeant caught me: "there's a new case up on 2nd floor; go check it out". Just as I thought, as I moved to the electronic medical record and started to skim the material. Don't ever plan ahead. But the flip side of that is: you are NEVER bored here!

Minutes later, I was interviewing the suspect about the alleged swallowing incident. "Just the facts, ma'am", and so she gave me the facts. Then I talked to the persons taking care of her, asking them for the same facts. They gave me different facts. My partner gave me some facts from a book. Those facts kinda said: maybe A, but it could be B as well. Should I call forensics in on this one?

The evidence had to be procured, and so I started to work the crime scene. "Try a bite of this", then "How about a drink of ______?", followed by "Would you like to try this, or THAT??"; and then finally, "Tell me what you would like next". Always, pacing the presentation of the spoon - so the suspect had to exert active control over the material; always, awaiting her subtle bloop of the hyoid up and forward, so then another bite/sip could be offered. Always, keeping that subtle but vital communication flowing throughout the meal, so that the suspect could eat and drink to the best of her ability.

Case closed. There was to be, at least today, no end of the shift with hearing a sentence pronounced: "mechanical soft, nectar thick- THIRTY YEARS TO LIFE". This is the city. I carry an IOPI.

Happy Better Hearing and Speech Month

May has been known as Better Hearing and Speech Month in the United States since 1927. During that year, the Holland Tunnel opened to feed traffic into and out of New York City. The Marines invaded Nicaragua and stayed until 1933. Heisenberg developed a theory of physics, but he was uncertain. The movie "Metropolis" premiered, and it certainly set the screen world on its ear. In the same vein, the American Speech-Language-Hearing Association (ASHA) set out that year, to tell the public about disorders of communication. ASHA also started to tell the story on what speech-language pathologists can do for the individuals afflicted with these disorders. So much has changed since 1927, but Better Hearing and Speech Month has not. This year's theme is titled "Communication Takes Care". Activities, events, and public relations tools are used to spread the word about what SLP's do for the persons we serve.

How do I want to commemorate the month? Above all, I want to say "thanks" to my current and former employers, for giving me the chance to serve persons in need. I have grown tremendously as a professional, from the wise experience and advice I had received from patients, their families, my colleagues and my peers. Following is a list of those employers.

* Kindred Rehabilitation Services, Streamwood IL
* Payne Wellness Center, Schaumburg, IL
* Brookdale Senior Living, Des Plaines IL
* Independence Plus, Inc., Oak Brook IL
* Elmhurst Memorial Hospital, Elmhurst IL
* Michael Reese Hospital, Chicago IL
* Allendale Association, Lake Villa IL
* Exceptional Persons, Inc., Waterloo IA
* University of Northern Iowa, Cedar Falls IA
* Covenant Health System, Waterloo IA
* State of Idaho Dept. Health and Welfare, Rupert ID
* State of Louisiana Dept. Health and Welfare, Thibodaux LA
* Assumption Parish School Board, Napoleonville LA
* University of Iowa Healthcare, Iowa City IA
* St Luke's Methodist Hospital, Cedar Rapids, IA
* University of Iowa, Iowa City IA
* Mississippi Valley State University, Itta Bena MS
* Veterans Administration Medical Center, Gulfport -    Biloxi MS
* University of Mississippi, Oxford MS

Happy Better Hearing and Speech Month, everyone!