By Lisa Yauch-Cadden
“I hope you had a good day”
My family and I are ABC News fans. I always loved Peter Jennings. I, like many people was saddened at his passing, and I thought my news program would never be the same. I liked Peter’s sense of gravity and calm. He was always well so spoken and articulate, even in times of crisis, even when he was speaking extemporaneously – now that was a man you could trust. I now like Diane Sawyer very much, better in fact than I thought I would. But in between Peter and Diane, there was Charlie Gibson, and I loved Charlie. I thought he was great on Good Morning America, was happy when they brought him back and was really happy when he picked up the evening news. He had a fatherly, folksy way of delivering the news, was also well spoken and he had a great sign off – “I’m Charles Gibson and I hope you had a good day”. I loved that! What a great way to end a newscast. After all the bad news he’d delivered, he encouraged us take a moment to reflect on our day, and for me, that was refreshing, because I rarely had an opportunity to think about that when I was working 8, 10, 12 hours a day and always wondering what I had to do next.
I find that even now, when I am working just 30-35 hours a week, primarily in one location, with very little travel, that I can still get caught up in my day; rushing from patient to patient, worrying about productivity, always thinking: What do I have to do next? What else can I get done? What have I left undone? What’s on the schedule for tomorrow? Only recently, have I been able to slow my thought processes to reflect on my day. Was it a good day? Did I make a difference? Did I help someone? Did I contribute? Lately, I have been able to answer “Yes” to these questions, and to answer Charlie, I am having more “good days”.
So what’s changed? My caseload is about the same as it was a year ago. It goes up and down with the hospital census (and the flu season). The out-patient schedule is fairly constant. The productivity demands are the same. There has been no significant change in personnel as it relates to my position. So the difference must be me. I have changed how I look at my job. I am still cognizant of the productivity demands. I am still accountable to lots of people, but my top priority is to be of service to my patients – to do the best job I can and to provide them with as much information as possible to make decisions about their care, as it relates to my portion of the treatment plan (usually swallowing). I spend time educating patients and families, reviewing MBSs in detail, providing treatment beyond just the diagnostic kind, establishing home programs and making sure they understand what their options are. I am not successful 100% of the time, but more often than not, I feel like I am making a difference. When I reflect on my day, I can say, “Yes, it was a good day”.
I think if we can all find those small moments, those 1 or 2 patients, that if not for you, they might not be doing as well, that through your knowledge or kindness, you improved the quality of their life or their opportunity for a better outcome. If we can reflect on those things at the end of the day, we can all have a good day and look forward to a better tomorrow.
About the author
Lisa Yauch-Cadden was born and raised in the Detroit, Michigan area. She has a Bachelor of Science degree in Biology and a Master’s in Speech Language Pathology from the University of Michigan. She has worked as an SLP in nearly all facets of the field: skilled nursing facilities, home care, acute care, transitional care, medical offices and schools. Throughout her career as a therapist, manager and business owner, Lisa has never strayed from providing direct line service, including state of the art evaluations using FEES/FEESST and MBS. While she needs no accolades to do her job, she is deserving of many. Her tireless efforts to advance the best clinical practices in Speech Language Pathology have changed lives for her patients, her clinical fellows, and those of us lucky enough to work with her on a regular basis. Contact Lisa at firstname.lastname@example.org.
If you have something to say, please submit your article for consideration to email@example.com. .…Read more ›
Clinical Colleagues Confidential is an on-line community for Speech Language Pathologists.
We have featured articles and opinion pieces that we hope you enjoy, but our main focus is to provide a forum for communication disorder specialists to communicate with each other – a virtual water cooler for professionals to gather and chat.
Our professional lives are spent in the pursuit of better communication. We study speech and hearing from phonemes to conversation to learn everything possible about the process of expressing and receiving language. The research into communication is fascinating in its own regard. But, we get to take research further. We bring it back to reality. We use the theoretical principles in functional settings, with people who have never achieved, or who have lost the skill, which is a distinctive feature of human beings: speech.
There may be no more meaningful work than giving another person the tools to complain or the means to tell their family how much they love them or to simply proclaim to the universe, “I am!” It is usually hard work. It is often poignant work. And, in our current practice settings, it is lonely work. Like the rogue cops from ‘70s TV shows, speech language pathologists and audiologists work alone. Even in small skilled nursing facilities and hospitals PT’s have PTA’s and OT’s have COTA’s but SLP’s are singular assignments for the most part. Our associates in other disciplines maybe very supportive, but few share our excitement for the free floating hyoid, the semi-circular canals, or the Masako Maneuver. Almost none of them have ever heard of Charles Van Riper or Hildred Schuell.
Who do we talk to when our compensatory strategy to circumlocute sends a ninety year old grandmotherly Broca’s aphasic into a profanity laden tirade? What ear can we bend when a trached preschooler chokes on the ground diet we recommended? How can we share our frustration about our Regional Supervisor, who doesn’t get it that bedside evaluations are longer than fifteen minutes, regardless of payor source? Where do we get to have our say?
Here. The website designed by speech language pathologists for speech language pathologists to discuss speech language pathology.
Welcome to Clinical Colleagues Confidential.… Read more ›
1. Cookie of choice (for bedside swallow exams)
- Graham crackers
2. BDAE or WAB (for language testing)
3. +/- or PICA (for scoring)
4. Muppets or dwarves (for entertainment purposes only)
4a. Favorite individual muppet
5. Worst treatment moment of your career.
- When a home care patient fell while ambulating to the table.
6. Best advice you ever ignored.
- Mom Mom always said, “Never trust a man with a beard.”
7. Favorite, most reliable and practical treatment strategy.
- Putting dysphagia patients’ medication in ice cream to facilitate the swallow.
8. Why SLP and not world domination?
- No, it’s not possible.
9. Would you do it all over again exactly the same way?
10. What one thing do you still want to do before your career goals are completely achieved?
- Teach nursing students and caretakers about swallowing.
SHAMELESS SELF PROMOTION IN 30 WORDS (there actually is no word limit really so say whatever you want).
- Kathy O’Grady MS CCC SLP is a graduate of the University of North Carolina at Chapel Hill. She has spent her career treating adults with neurological deficits which effect speech/language/swallowing/cognition. Her work has taken her through multiple states and a variety of settings. She is equally at home in rehabilitation hospitals, home care, or skilled nursing facilities and can easily juggle the demands of a front line therapist, rehab manager, and supervisor. Truly a gifted resource and valued mentor, I am most pleased she took the time to participate in the 10’s
However impressive her achievements in the clinical arena are, they pale in comparison to Kathy’s greatest skill; Mom. She adopted her daughter from China eight years ago, as a single woman, and is grateful each day for this blessing.
She and her daughter would like to take this opportunity to encourage loving individuals and families to learn more about adoption and support groups working to find children who are alone, the family they so desperately deserve.
Sadly, there are so many more children needing families than there are people able to meet their needs. Wonderful organizations exist to aid those children so they too know they are loved. One such group is Half the Sky which works with orphaned children in China. Their website can be found below:
Send feedback to Kathy to firstname.lastname@example.org…Read more ›
By Alexandra H. Solomon, PhD
Carrying the Hope, Part 1
Autism Spectrum Disorders: A report from the trenches
“Mom, you have to come and look at my poop!” Brian yells, running back into the office where Fran, his therapist, and I are patiently awaiting his return. His blue eyes are shining, he grins from ear to ear. He gestures to me (“come here!”) and then runs and grabs my hand. When I arrive at the potty, I glance at the specimen and then at Brian. His eyes are glued to me, anticipating my reaction. I smile, he laughs and spreads his arms wide, “it’s the longest snake ever!”
Such a moment might not strike everyone as so wonderful, but to me it is utterly amazing—and on so many levels. When he was 26 months old, Brian—now six–was diagnosed with PDD-NOS (Pervasive Developmental Disorder, Not Otherwise Specified), which is an Autism Spectrum Disorder (ASD) falling somewhere between Autism and Asperger’s Disorder. Although even then he was considered “high-functioning,” he was dealing with some pretty significant problems for such a little guy. He had painfully sensitive ears (auditory hypersensitivity), no interest in other kids, aggressive behavior toward himself and others, scripted language, limited play skills, minimal social referencing, chronic diaper rashes, and continual gastro-intestinal problems, vacillating between constipation and diarrhea.
Now, at six and a half, thanks to intensive early intervention that was truly biopsychosocial in nature, Brian is making great strides. His current diagnosis is Asperger’s Disorder, rather than a PDD-NOS diagnosis. Also, not only have his physical/medical problems improved dramatically, but he is now competent enough at relationship skills to want to show me something he made, to figure out how to get me to come see it, to wait for my reaction, to celebrate with me, and summarize the whole event with a declarative statement.
When Brian asked me to come and look at his poop, he was not trying to get me to do something for him or make something happen. He wanted me to share an experience with him purely to share it. He also used gesture, engaging in non-verbal communication both receptively and expressively, which even six months earlier he simply could not do. This level of social referencing (defined as the ability to read, recognize, interpret, and respond to others’ facial expressions and tones of voice), coordination, and experience-sharing is extraordinarily difficult for a child with an ASD. Odd as it may sound to those unfamiliar with Austism Spectrum Disorder kids, what Brian did is a very, very big deal.
Mommy instinct: Something is not right
Brian’s first year of life was unremarkable—marvelous to his mom and dad, of course, yet unremarkable. He met all of his early milestones on the late side of normal and was social and sweet. At his 15-month well-child visit to the pediatrician, he received a clean bill of health and (I now believe) a fateful combination of two vaccinations— the measles, mumps, and rubella (MMR) shot and a flu vaccine. After the vaccinations, he spent the next three months sick more often than he was well. He battled bout after bout of diarrhea and became extra-sensitive to sound. He seemed tense a lot of the time and preferred repetitive solo play—pulling the books off his shelf and “reading” through them over and over in the same way. He also started to pull hair—my hair as well as the hair of the moms and kids at music class. He didn’t seem angry when he did it, just tense.
However, by 18 months, he could count to 100, knew all of his letters, and was beginning to do phonics (“Brian, what letter does ‘lavender’ start with?”). Nonetheless, at his 18-month visit, I asked his doctor how I would know if he had Autism. She said, “Does he point?” I said, “Yes.” She said, “He doesn’t have Autism.” I was relieved.
As I look back on this interaction, I realize how much the doctor really missed the mark with her cursory screening attempt. Brian did point (“Where’s the cow?” I would ask, and he would obligingly point at the cow in the picture), but he was not demonstrating joint attention in an age-appropriate way. Joint attention, a readily mastered milestone for a neurotypical child, means that the child looks at something—a balloon that has captured his interest, for example—then at mom to make sure she sees it, then back at the balloon. This attempt to engage with his mother in joint attention¬—hers and his together–is lacking in a child with ASD, and it is an important diagnostic indicator.
At Brian’s two-year-old visit, I expressed clear concern. Brian hated being around other children, he was self-injurious when frustrated (biting himself and sticking his fingers down his throat), his hearing was painfully sensitive, and he was crazy-good at math (at that point he could identify any three digit number, and he was beginning to add). I didn’t consciously know what to call this, but the combination frightened me. The doctor simply told me that he was a math genius and that I needed to become a better disciplinarian. “Everyone has quirks,” she said breezily.
There’s a name for it
After another week of comparing my son to similarly situated children and feeling with every comparison that something just wasn’t right, I called my pediatrician again. She told me that she had actually been thinking about Brian too and that we ought to seek an occupational therapy evaluation in order to rule out a “Sensory Integration Disorder.” I had never heard of this, and it did not appear anywhere in my DSM, but we went ahead with the evaluation at a local clinic.
The occupational therapist decided that yes, in fact, Brian suffered from, “auditory hypersensitivity, low muscle tone, motor planning delays, and vestibular and proprioceptive hyposensitivity [low responsiveness] ” The vestibular system, located in the inner ear, controls head and body movement, balance, and posture and also influences other sensory systems. The proprioceptive system refers to information from the joints, muscles, tendons and ligaments telling you where your body is located in space. According to the occupational therapist, Brian attempted to make up for his under-responsive vestibular system by seeking out swinging, jumping, and sliding, but would become overwhelmed by the stimulation and then upset. He attempted to compensate for his under-responsive proprioceptive system by seeking intense experiences of physical contact, squeezing or being squeezed, jumping, crashing, and pushing (usually other kids!). In short, there were multiple ways in which his sensory system was skewed, resulting in anxiety and behavior problems. The recommendation was for two hours a week of occupational therapy at the clinic. We were sad and a bit confused, but we started the therapy as instructed.
Still seeking more information, I reached out to a colleague of mine, a psychologist, who specializes in working with children, and she recommended that we seek a full neuropsychological evaluation in order to check “all of Brian’s lines of development.” OK. We headed to a neuropsychologist at a well-known clinic, specializing in neurobehavioral problems. On the way home from the first session, which included some assessment of Brian and some interviewing of me, I began to panic as I replayed her questions in my mind: Does Brian have language anomalies, like reversing his pronouns? Does Brian use gestures like nodding and shaking his head? Does Brian spontaneously direct your attention in order to show interest? I knew that I was answering nearly all of her questions “the wrong way,” indicating a less-on-track rather than more-on-track child. I got home and opened my DSM to the chapter I feared the most, the chapter on Pervasive Disorders of Childhood. I called my husband sobbing, “This neuropsychologist thinks it’s autism. Holy shit, she thinks it’s autism!”
Indeed, on November 9, six days after the birth of our second child, Courtney, we were told that Brian met the criteria for a “provisional diagnosis of PDD-NOS.” Reality sunk in only slowly over days and weeks. I hear this frequently from parents of children like Brian. The mind and the soul cannot take in all of the meanings, feelings, and unknowns at once–it is too disorienting.
Those early months post-diagnosis are an existential mess for all parents, and they tormented me. As we started to tell family and friends, no reaction was the right reaction. I remember my mom’s cheerful voice telling me, “He is FINE! He is more than fine. The only problem Brian has is that he’s too smart for his own good!” But, we had just been told that he was not fine, and her reaction hurt me–it felt like an invalidation of the struggles we were up against. On the other hand, I remember my step-mother’s heavy voice telling me, “My heart is breaking for you. I am just so sorry for you.” Her reaction hurt me too. Her heart should not be broken—this was not a death sentence. We’ll get him what he needs to catch up, I told myself stoutly, and he’ll be “indistinguishable from his peers” by kindergarten (the often repeated goal of early intervention).
True, Brian was still the same boy he had been before the diagnosis, and I resisted looking at him differently. Yet, he also was not the same boy. He was now a boy who could not and should not be expected to do what other children do. I could feel the ways in which the diagnosis, the label, was becoming a lens through which I experienced him. Autism was beginning to infiltrate everything.
*We had always laughed about how Brian’s transitional objects were never stuffed animals or blankies. Related to his deep and abiding love of numbers, his favorite form of comfort always came in the form of an “8”—an 8 of clubs from a deck of cards was the best, but sometimes a magnetic refrigerator 8 or even a hair elastic twisted in half could do the trick. Indulging the love of 8s was now tantamount to reinforcing the autism, but not allowing him to seek comfort with an 8 felt cruel. I was stuck. The 8 of clubs now seemed symptomatic of the autism because one of the DSM criteria is about “restricted interests” for example being “highly attached to some inanimate object.”*
I also had become my own worst fear– the mother of a child with special needs. I remember, long before I became a mother, seeing the mothers of disabled children and pitying them—how shameful for me to admit. And, it was autism I feared the most. The little that I did learn in graduate school about it terrified me. How could I survive having a child who was not responsive, who could not give love? Of course, my stereotype of autism was skewed. I have never met a mother who described her child with autism as unable to give love. But, long before I faced autism, I feared it deeply.
Thankfully, there is just too much to do post-diagnosis to wallow for long in grief and anxiety. The neuropsychologist told us that there is a limited window of opportunity for effective early intervention and that in order to minimize the impact of Brian’s disability (I could not believe that I was hearing that word!), we would need to start therapy right away. She also told us that his young age, his ability to use language, and his apparently normal intelligence all worked in his favor. In a few years, she suspected, he would meet the criteria for an Asperger’s Disorder diagnosis: he would be high functioning, whatever that meant.
We wanted a crystal ball. We still do. Would he need special education? Would he make friends? Would he go to college? Would he live independently? The last question is still the most terrifying. I still cannot hold in my mind for more than a moment the image of my son living in a group home. He simply must “get better.” The neuropsychologist, of course, could not answer any of these questions. She could only tell us the list of services that he would need ASAP. Her initial recommendation was for individual developmental play therapy, a play therapy group, speech therapy, and occupational therapy. She had some ideas about which local clinics we could contact.
The next month was a blur of phone calls, initial appointments, sleepless nights with a newborn, and hours upon hours spent on the computer trying to understand this world we had just entered. The neuropsychologist had suggested that we limit our internet research as there was a lot of misinformation out there. That was the only recommendation that I did not and could not follow. I was glued to the internet and on a steep learning curve. The quest for information functioned on multiple levels. Doing it contained my anxiety and also gave me enough confidence to trust my instincts about providers, navigate the tricky shoals between contending treatment philosophies, and decide upon a way to proceed that made sense for me.
To be continued………
Please look for our next installment when we learn about the therapies that the Solomons selected, how Brian responded and how the family has been doing.
About the author
Dr. Alexandra H. Solomon is a licensed clinical psychologist and a clinical lecturer in Northwestern University’s Masters of Science in Marital and Family Therapy program. She received her PhD in Counseling Psychology from Northwestern University, as well as a graduate certificate in Gender Studies. Dr. Solomon has developed expertise in the areas of couples, families with special needs children and group relations/ dynamics. She has published a number of articles, most recently about parenting children with Autism Spectrum Disorders (ASDs). She has presented nationally on this subject and consults to the media on topics related to marriage and family. Dr. Solomon is a member of the American Psychological Association (APA) and the American Family Therapy Academy (AFTA). In her free time, Ali can be found enjoying hip hop dance, running, biking, swimming and competing in the occasional triathalon. Contact her at email@example.com…
By KT Leary
The Universe Tries To Right Itself
On August 6th 2009, my daughter, Erin, died at 11:15am, as a seat belted passenger in a car driven by a friend on the way to a mall. Erin and four friends were trying to purchase one more concert ticket for a friend, so they could all attend a Blink 182 concert that evening. The vehicle was speeding, being driven erratically and it hit a guardrail, rolled over, hitting the cement median also. Two passengers died, Erin and her dear friend Jason, both seated in the rear. Erin had just turned 16 and Jason was 17.
Erin had been ill for four and a half years with aggressive colitis and had survived the removal of her large intestine in January 2009. She was finally healthy, off all medications, and excited to embrace her life. She discovered what most teens in Hull, MA knew. That jumping off the A St. pier into the bay was a summer right of passage. She did well in school, was loved by her friends, and knew the meaning of resilience and compassion. She volunteered for many causes, and especially loved helping at the Paragon Carousel.
To say that her older sister, Shannon, and I are devastated is an understatement. Our world forever changed; we would reel from this blow every moment of our lives. Shannon needed to leave for her first semester at college three weeks after Erin’s accident. Due to a shortage of dorms, some students were housed in studio apartments, as Shannon was. She struggled to adjust to this greatest of losses, being alone in a new place, and the workload. Four months into school, Shannon decided she wanted a cat to keep her company, and help her through her emotionally battered days. She and I adopted a young calico cat from the ASPCA.
We brought the very magical cat home from the shelter, and named her Aylen. She is sweet, gentle and affectionate, and reminds us so much of Erin, in some otherworldly way. In trying to acclimate Aylen to my home during Shannon’s winter break, we introduced Aylen to our two dogs. They were fine together, until I without thinking, put the male dog’s food bowl down. Aylen rushed over and the dog attacked her, flipping her and breaking her leg. It was terrifying – could our loss be compounded by another so soon? How had I let this sweet animal be injured?
We rushed her to our vet. Then to the animal hospital where it was determined she wouldn’t die. Both Shannon and I cried in the waiting room: for Aylen, for Erin, for ourselves. We tried to explain our emotional state to the emergency aide. We were told Aylen needed either to have a splint or be operated on for two broken leg bones. The difference in price was $1,000 versus $4,000. We chose the splint and lesser price out of necessity. We went home numb.
I remembered I had planned to meet three friends for dinner that evening and I joined them for a short while to tell them what had happened and explain why I was so late joining them. I briefly explained about Aylen. We talked about Erin. We drank tea.
The next afternoon Shannon and I went to get Aylen and the same helpful aide took us aside to tell us that an anonymous donor was willing to cover Aylen’s surgery costs if we chose that for her. We both started to cry again. Disbelief. Kindness. Incredible Kindness. What was happening? Who knew where Aylen was being treated? Who could afford to do this? Why did this feel so strongly that it was mixed up with the loss of Erin?
The aide, Megan, took us into a private room so we might compose ourselves and try to comprehend what she was offering. We needed to decide quickly while the doctor could fit it in her operating schedule. What did we want to do? I asked Shannon to decide. In tears, Shannon said, “Maybe the universe is trying to right itself,” and then she said yes to surgery and a greater hope for full recovery of Aylen’s limb.
Aylen came home with six pins in her leg and two blue bars holding them in place. After six weeks they were removed and she went to live with Shannon in Boston. She is fully recovered. I have visitation because I fell in love with her too.
We honored the donor’s right to remain anonymous, asking only that the vet mail a letter from us, with Erin’s picture, Aylen’s picture, and our immense gratitude expressed inside.
About the author
KT Leary is the mother of two residing in a tiny, coastal community just south of Boston. She is a chef and volunteers for many worthy causes including Lakota Kidz http://www.lakotakidz.org/ She was kind enough to share this poignant story of her enormous loss and the small, subtle ways the Universe tries to comfort us. I’m certain she would be most grateful if anybody reading this article was motivated to go out and commit a random act of incredible kindness in memory of a really good kid, Erin Leary. Please feel free to send updates of your Random Acts of Incredible Kindness and I will forward them to KT and Shannon. firstname.lastname@example.org…
By Marguerite Mullaney
“I have all these answers but nobody is asking me any questions!”
The words echoed down the muggy hallway of an Alzheimer’s unit one hot August afternoon as I was hurrying along to see my next patient. They stopped me in mid step. Many times, a patient has managed to say the one thing I needed to hear at a particular turning point in my career. However, on this occasion, the message was shouted by somebody not on my list with no assigned minutes. His sentiment was so poignant and so common it could be a defining human characteristic; the need to share our expertise. It is a want that resonated deep within me and I took a few minutes, unbillable minutes finding the man and asking him a question.
We spend years becoming speech language pathologists. Studies are not enough to get the seal of approval. There are tests to pass, followed by a lengthy fellowship under the watchful eye of another person already judged to be an expert. Even certification and licensure is a process and requires constant education to renew yearly.
Yet, having completed the all basics and continuing to achieve certification and licensure yearly, I find nobody is asking me the question I so desperately want to answer. If I had a chance to answer one question for the next generation of SLP’s, I already know what I want to tell them. It would be the same message given to me by one of my graduate supervisors.
I was her first student. She was my first supervisor with an adult neurogenic population. We spent the autumn of 1987 driving each other crazy and getting in each other’s way. She wasn’t easy to learn from and I wasn’t particularly bright, but we bumbled along with a minimum of chaos. Then dysphagia struck!
Swallowing was a bit new to SLP in those days. Not every clinician was practicing it. I was lucky. My supervisor was confident enough to admit her limitations. She showed me how to research the information I needed to fill the gaps in my university education. There was no dysphagia course offered in my graduate program way back in the dark ages of the eighties. Filling in my theory short comings was as easy as reading; Logemann and Rosenbeck became my bedtime stories for the remainder of grad school.
But, practical application of that knowledge takes…PRACTICE. You need to do an awful lot of awful bedside evaluations before you get really good. You need to see an ocean on aspiration on MBS before you can anticipate the drowning. How does a supervisor get a new clinician from inexperience to expertise without killing anybody? The answer is not, ‘puree and pudding thick liquids for everybody.’
Have the clinician answer this question just as my supervisor made me answer for each of our dysphagia patients 23 years ago: “What swallowing felony has this patient committed to be condemned to puree and/or thickened liquids?”
Too many times lately, I’ve read reports which did not reflect deficits significant enough to justify diet modification. Then there’s an increasingly popular trend in acute care summaries which apply the safest diet for swallowing purposes without consideration of the ramifications to the whole patient. Expensive MBSs performed in which no aspiration was detected or the trials were less than five swallows or limited trials of nectar, honey, and puree or not one compensatory strategy attempted have been in over-abundance in recent years. Bedside evaluations are sent with statements identifying aspiration to the point you must read them twice to be certain imaging was not conducted. In my pursuit of additional information for some of the more outrageous claims, I have heard such depressing excuses as:
1) I stopped the MBS because I was afraid the patient would aspirate.
2) The patient was coughing so I changed him to pudding at bedside.
3) I didn’t try thin during the MBS because at the nursing home he was already on nectar so I started there.
4) There’s no speech at nursing homes so I put her on the safest diet; puree and pudding thick.
5) A suspected timing delay of the epiglottis might be present and could lead to aspiration even though none was apparent on the MBS but to be safe I recommend nectar thick liquids.
6) I didn’t want to recommend something they might aspirate and get sued.
I wish there was no number 6. Sadly, I think it is the driving force behind many of the recommendations. But, I would spread some words of caution to my peers, especially the younger ones. The only thing that avoids litigation is luck. The thing that wins litigation is expertise and documentation.
If you make a swallowing recommendation in isolation of the needs of whole patient to save him from aspiration pneumonia and he goes into renal failure…that’s a big problem.
If you base your recommendations on what you suspect their living arrangements are and you are wrong…that’s a big problem.
If you are practicing limited trial MBS’s and ending them early because you are afraid the patient will aspirate…PLEASE stop conducting MBS and get more education!
Before you alter another diet ask yourself, “What swallowing felony has this patient committed to be condemned to puree and/or thickened liquids?”
About the author
Marguerite Mullaney was born and raised in and around the Boston area. She continues to make her home in the Commonweath and rarely finds it necessary to travel beyond the 128 belt. Her undergraduate program was completed at Bridgewater State College and she attended Northeastern University for graduate school. Adult neurological disorders has been the primary focus of her clinical practice. Her vast knowledge of the field, thoughtful, pragmatic approach and incredible sense of humor have enlightened and inspired her patients, staff and colleagues for over 20 years.…
By Michelle Sachs Clapp, CCC-SLP
Back in 1998, I was working with the geriatric population in a SNF setting. The pay was good and I enjoyed my job- at least the direct contact with my clients and the camaraderie with my coworkers. What I didn’t like was the growing amount of redundant paperwork required of me and the increasing demands and tightening criteria of what counted as “direct” or billable time.
I was forced out of this setting by the changes in Medicare standards and the fact that I was a “dinosaur” in the field- I had over 15 years of experience as a speech/language pathologist and it cost agencies or facilities a lot more to keep me on or to hire me than a more recent graduate with less experience. After being “offered” a 33% pay cut along with the promise of a pink slip in a few months, I re-examined my career choice within my chosen field. The job market was not promising for me in light of my years of experience and the pay had been cut drastically, due to the new methods of reimbursement ( direct, billable time as opposed to salaried). I had two young children and although I didn’t have to work full time, I did still have to work to help pay the bills. I decided to apply for a position with a local early intervention agency that was advertising for a speech/language pathologist.
At my interview, I feigned great interest in working with little children, even though I felt that I had little patience for this population. I played up the experience I had from years and years ago working in the Head Start program and with elementary school children. Sure enough, a position was offered to me- 2 days after I was offered a per diem position with 3 SNF’s in a not-too distant town. I accepted the per diem position. Within 2 days on the job, I knew it was a mistake. Criteria for who qualified for my services severely restricted who I could work with, regardless of my professional opinion of who would benefit from my assistance. I could see that I would be spending a lot of time with minimal financial reimbursement. And the paperwork was quite overwhelming as well.
I called the early intervention agency that had offered me a position and indicated to them that I was still interested in them, if they were still interested in ME. They called back and our partnership began.
For the first year of my new career with little ones, it felt like I was paddling upstream; it had been years since I had worked with pediatrics and I was behind in skill, knowledge, lingo, etc. I worked directly with the children and their families during the day and studied and read up on pediatrics on my own in the evenings. After my first year there, I finally felt comfortable enough to start widening my knowledge base by taking on a more varied caseload, reading additional materials about non-speech/language issues with this very young population, and really listening to and doing co-visits with my non-SLP co-workers.
To summarize, I am now completing my 11th year working in early intervention! I love what I do. I feel like I rediscovered my field of work and put my heart into what I do. I feel very alive in my daily work and the rewards are priceless. The pay may not be as much as it is now in SNF’s, but the benefits (being paid with hugs, kisses and holiday photos) more than make up for the lack of monetary compensation. Way back when, when I was applying for this position, I thought that I was faking my enthusiasm about this population but much to my surprise, I discovered that I love love LOVE working with these little ones and their families! I have plenty of patience for them; I guess it was my OWN kids that I had the lack of patience with! Although, as I get a bit older, it gets a bit harder getting up and down off of the floor from my visits, I will continue to do so for as long as I can and will continue to learn about and take on the various challenges that working with the 0 to 3 year old population holds for me.
Michelle Sachs Clapp MA CCC SLP graduated from University of Delaware with a BA in Communications and completed her MA at Ohio University. Since entering the field, she has worked in a variety of treatment settings but finds her current position in early intervention to be her favorite. In addition to her career in Speech Language Pathology, she has honed her parenting skills over the years raising a daughter, son, and soon to be stepdaughter. Her happy home life is fully rounded out by the love and affection of her cat and dog. She has practiced Kundalini Yoga for the last 9 years which maybe how she maintains her charm and humor when life presents unexpected changes.
Michelle is a good friend and an excellent clinician. It was a distinct privilege to work with her so many years ago when our careers as SLP’s were shaken to the core by PPS. I am honored that she agreed to share her method for dealing with the January 1999 reimbursement changes for SNF’s. These regulations continue to test the patience and ethics of individual practitioners across the country. As we prepare for the next round of changes, Michelle’s experience serves as a timely reminder of all the opportunities our profession affords us.…Read more ›