Adventurous

That's right. I said it. Practicing speech - language pathology requires an adventurous soul. As Merriam - Webster implies, speech - language pathologists are "disposed to seek adventure or to cope with the new and unknown".

You may have that day received numerous referrals for swallowing, many of them the aftermath of a single coughing episode for each person. Your treatment day may be marinated in boilerplate writing, to help keep the doors open. Meeting a milepost for your day, alongside that of a colleague, you may be asked "How many (patient appointments) do you have left?" Rapid rewrites of your daily schedule, require your turning on a dime to meet changing attentional demands by our customers. Get that documentation done before the end of business. Make the telephone calls. Attend the meetings, scheduled and impromptu. You have a productivity target to meet. Make sure you have all you need, to do the night work that lifts your work to the highest level of quality. Get it done. Do it!

You can hear in the background the pounding rhythm of "Working for a Living", by Huey Lewis and the News.The thumping; the pressure. There's always a need to strive, to push and to grasp the next rung on the ladder - surge ahead on the long staircase that is the rehab journey, to arrive at the next landing to gain perspective. What makes speech-language pathology work, adventurous? How does the CSD clinician prepare for the adventurous life? How does a professional plan for success, in such a workaday world?

I see an individual clinical encounter as dripping with adventure. Bold? Risky? Speech-language pathology? After all, you as the person's clinician guide persons served to tap energies they scarcely recognize within themselves. Changes in bodily function have apparently occurred out of the blue, and the person is often clueless how to remedy such a catastrophic event.

You are well prepared by training to take the arduous journey that evaluation and treatment represent. Your adventure begins with leading the person beyond her limits of perception, of motor power or of reasoning. Does she find the strength to recover from being lost in a dark wood, not able to affect change in her skills without your help?

With the evaluation done, there is the refocusing of the quest to achieve the person's goals. When the person served can contribute energy to identifying and clarifying the goals, the road to reaching them is clear. A clear path to the person's goals helps give agency to the person, and makes her the one wearing the armor.

An adventurous quest to achieve treatment goals may still bring many challenges; physical, psychological, financial, spiritual, and so forth. There are hills to climb, torrents to ford, monsters to confront and territory to claim. The person served learns to recognize decision points to be met during her treatment program. She gains confidence for acting as it is needed, and when it is needed.

The quest may, regardless, seem contrived, complex, cumbersome and "not real life". The person served may sometimes say, "I'm never going to use this". The adventure of a person's treatment program will stand the test of time when done right - when the goals sought after are firmly in hand, when the future is easily imagined, and quests are yielded to others more in need.

On the other side

When my wife learned of her diagnosis this past summer, it was a challenge for me to 'stay clinical' about the situation. Meldrick Lewis, that wisecracking detective from my favorite cop show, had said once that homicide detectives working a case should keep everyone around them 'at a distance'. That has been one of my strengths as a CSD clinician over the years; one of my marketable skills as an SLP. No matter the noise about the person I had been helping; no matter the amount of stress in my day; - I could keep it clinical, blocking out the clouds of peripheral activity to the case and to myself, - I could say, it's just agitated behavior. It's just the patient urinating on the chair, or it's Capgras syndrome - she's still a human being and my patient. My responsibility to her is to focus on the reason for skilled SLP to be called in.

My wife is not my patient. It's the slicing open of my clinical mask by her recent medical status change, that has made me newly aware of the following: When you're on this side of the encounter - when you are personally involved in a treatment program - it's not so easy to stay indifferent to the emotions that rattle and slap against you. You can't easily push back the anxiety, the fear, the puzzlement, the latent skepticism, or the stark reality that you feel utterly powerless against these medical 'forces'. But, I initially told myself - you know the system. You even know a bit about this medical condition, and what can be done. That led to a relatively large conundrum for this healthcare worker, one that is related to the contemporary psychological dictum - it's not just about you.

 I live in the caregiver's world now, albeit a fairly literate caregiver when it comes to health knowledge. I can deduce the effectiveness of medications, and follow directions for treatments. I can approach doctors, nurses, social workers and all their ilk assertively, to deduce their thinking about what needs to be done. But I ultimately have no power; at least no clinical power, to help steer my wife's outcome towards its conclusion. Caregiver power is regardless, substantial.

It's an entirely different skill set - one based on intimate knowledge; attentiveness; patience; the big picture; the little things; not sweating the small stuff; not dropping the ball; being there and celebrating every little success on the journey - celebrating every landing that is reached, on the long staircase my wife is climbing towards her recovery. It's a switch in my psyche that I toggle now; namely, to go between the clinical professional and the grateful caregiver. Grateful I get the chance to be there for her when she needs it. Grateful that I can empathize better, with the caregivers of my patients I meet almost daily.

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!