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Pandora’s Box

Pandora’s Box

Here are some recommendations for the busy clinician.

My  New Favorite Thing:

SLUMS is a great tool for screening patients.  It is a very quick 11 item test which looks at attention, cognition, and language.  While there is a form, most of the items are so simple you can recall it from memory after giving just a few times.  Follow this link to there page. 

http://aging.slu.edu/index.php?page=saint-louis-university-mental-status-slums-exam

 

No budget? Grab these and go:
Paper, pencil, pen, sharpie, penlight, plastic cup, spoon, watch, post-its, newspaper, blank/starter check, pocket change.

With these 12 things, you can assess confrontation and responsive naming, single and multi-step direction following, auditory and reading comprehension through the paragraph level, oral reading, problem solving, calculation, and functional writing. You can also create simple communication boards, visual/reinforcer schedules and pacing boards.

Have a little money?
This is a great time of year to troll the yard sales for toys, books, reinforcers. Look for Mr. Potato Head, Little People toys, and Match Box cars.
Thrift shops have great finds as does the Dollar Store.
Enchanted Learning.com is a great website for reproducibles to create/modify lessons.
Super Duper articulation decks are great.
LARK Kit is a versatile language tool for adults.
DAF/FAF by Artefact is an inexpensive way to provide auditory feedback for dysfluency.
Movies and Music is a great language activity for older adults (www.moviesandmusic.biz)
Save your back with a bag on wheels.
Don’t forget contact paper and Velcro.

Have a lot of money?
Get an iPad and download some apps. Check back into the Treasure Chest for recommendations for cool apps.

Please comment and let us know what you like/can’t live without.

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I hope you had a good day

I hope you had a good day

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 lycslp@gmail.com.

If you have something to say, please submit your article for consideration to lycslp@gmail.com. .…

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10’s by Kathy O’Grady

10’s by Kathy O’Grady

1. Cookie of choice (for bedside swallow exams)

    Graham crackers

2. BDAE or WAB (for language testing)

    WAB

3. +/- or PICA (for scoring)

    PICA

4. Muppets or dwarves (for entertainment purposes only)

    Muppets

4a. Favorite individual muppet

    Kermit

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?

    No

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:
http://www.halfthesky.org/

Send feedback to Kathy to mullaneycccslp@comcast.net

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Carrying the Hope, Part 1

Carrying the Hope, Part 1

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.

Reality bites
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 asolomon@northwestern.edu

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The Universe Tries To Right Itself

The Universe Tries To Right Itself

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. mullaneycccslp@comcast.net

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I have all the answers but nobody is asking me any questions

I have all the answers but nobody is asking me any questions

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.

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Unreasonable and Senseless

Unreasonable and Senseless

By Marguerite Mullaney

Unreasonable and Senseless

The cornerstone words in all rehabilitation treatment plans are reasonable and necessary. They have been the yardsticks by which our Medicare reimbursement intermediaries retroactively determine if a claim for service is covered under the Medicare A benefit or Medicare B plan. Seventeen years ago when I first walked into a nursing home and began to learn the rules for providing rehabilitation services in a Skilled Nursing Facility (SNF), reasonable and necessary were applied to every goal of each individualized treatment plan written for our patients.

I might mention, those plans were handwritten by the evaluating therapists. The goals were often agonized over to be sure they fit the reasonable and necessary parameters and could be measured should proof be needed of the final outcome. Way back in the 90’s, the therapist writing the goal was more than likely to be the person carrying it to completion. PTA’s and COTA’s were utilized as an additional resource but not the primary therapist responsible for weekly updates, monthly recertification, home evaluations, and discharge summaries. In short, they assisted the registered clinician in carrying the caseload. Then as now, Speech Language Pathologist cannot use an SLP assistant at SNF level and receive Medicare reimbursement as our PT/OT colleagues can. This means an SLP carries a caseload in much the same way he/she did almost two decades ago.

The rules changed in January 1999. The Prospective Payment System arrived! It was designed to cut Medicare waste and fraud. It was marketed as a means to control the spending at the SNF level which was rocketing out of control. Many inside the industry puffed about the system forcing ‘smaller players’ out of the market thereby cutting the ‘glut’ of skilled beds. We were being told at the time there were 1000 too many skilled beds here in Massachusetts. The extra beds were alleged to be driving up the cost of care.

I have a question: Our entire economy is based on supply and demand. Has there ever been another industry that drove the costs of services up when the supply was greater than the demand?

We are on the eve of adjustments to the reimbursement system. I’ve been told the regulations are going to get even tighter. To be honest, other than knowing rules will be added in October 2010, my knowledge of the changes are very limited. However, I feel qualified based on almost two decades practicing in SNF’s to make a prediction: Nationally based For Profit Corporations will become the primary providors of skilled care beds across the United States.

I have a second question: Large, nationally based for-profit corporations are created to make money and increase profits for their investors. Who will be paying the biggest piece of that revenue? Individuals? Private Health Insurance Companies? The US Government via Medicare/Medicaid?

I might mention here that regardless of clinical setting, the best reimbursement source for an inpatient rehabilitation stay is Medicare. Yes, the same system that was redesigned to control costs in January 1999. It is the system For-Profit Healthcare Providers want well-represented in their case mix. More than want, they rely on Medicare to make their bottom-line.

Here’s a rhetorical question for those who think I’m overstating the value of Medicare A and B to SNF’s: When was the last time anybody heard an Admission’s Director say they needed to fill more beds with Medicaid recipients?

I’ve watched over the last few years as the terms reasonable and necessary have been morphed into new packaging. Many rehab providers are using software systems that have goals listed and waiting to be plugged into an evaluation. Some software triggers the goal a therapist should pick. There are courses with watch words and buzz words to prep therapist to avoid writing an evaluation or a note with a RED FLAG. I’m a realist. I know those types of formulaic programming are a natural outcome of Intermediary Help Letters, Denials, and the dreaded RAC Audits. There is nothing wrong with giving therapists tools to practice within reimbursement guidelines.

But, something more insidious happened while I was distracted watching the major changes. A phrase entered the continuum of care very casually. In fact, it sounded like a good thing on first blush. It wasn’t until it was applied against the stark white of reality, that I truly understood the danger of the concept.

“We treat all our new admissions as ultra highs until they show us differently.”

It doesn’t sound bad. It actually captures the spirit of America. Everybody gets a fair and equal shot at their bite of the apple. Makes you think the care providers don’t pre-judge based on gender, race, sexual orientation, age, or ability. Sounds like equal protection. But, this is exactly the point where everything goes wrong.

We do an evaluation so we can pre-judge and prescribe the appropriate amount of treatment. Our recommendations are supposed to be based on what the patient is able to do during the evaluation. We must take into account their general health prior to illness, their premorbid level of daily activity, the course of their illness, their age, their family’s goals, and their own hopes for their recovery. We adjust the patient’s goals as the treatment plan succeeds or fails. Weekly notes and monthly recerts are there to keep us and the patient focused on progress, or lack thereof.

However, if the expectation walking in the door before we even lay eyes on the patient is that this very sick individual who has been in acute care for at least 3 midnights is to be able to tolerate a minimum of 35 minutes of treatment per day by 3 disciplines over 7 days with 3 hours of group time being evenly divided among disciplines, then the evaluation is completely superfluous.

Most nurses and aides and family members already know a patient cannot walk, eat, talk, or care for themselves. The therapists’ evaluation is meant to provide a means of rehabilitation and a plan of implementation. Computers are able to generate goals based on assessment data of strength/weakness. Assistants for PT/OT carry out most of the plans of care. And, now registered therapists have pretty much lost their authority to determine how much time is needed per day and how many days in a row are necessary to reach functional potentials.

I fear, we registered therapists across disciplines have just become rubber stamps for a plan of care designed, programmed, and packaged to meet the standards of a reimbursement system extracting the maximum dollar amount for care provided to any patient, regardless of their reasonable and necessary needs.

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.

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Great Expectations

Great Expectations

By Barbara Yauch

Great Expectations

As a mother of 4 adult children, two boys and twin girls, I have recently had the chance to reflect upon their lives and our life together. I have discovered that each one, in his or her own way turned out just as I had hoped and expected they would – independent, self-sufficient, strong-willed and successful adults.

The path to successful adulthood was not without its bumps in the road.

I recall being a young mother of two boys expecting my third child (a girl?, I’d hoped) . It was the 1960s and the pregnancy was proceeding as expected, until the sixth month, when my water broke. This was unexpected, after all, to this point, everything had proceeded normally, as expected. I believed I would deliver a healthy baby.

My husband and I traveled to the hospital, only to find interns, nurses and even the doctor saying, “very small baby”, “very big baby”, “ too early”, “you will be going home soon”. Each proclamation was wrong, and eventually, 10 weeks before my due date, I delivered not one, but two baby girls – 75 minutes apart. Talk about unexpected!

My husband and I were excited by the news. This was truly the buy-one-get-one deal of a lifetime. However, our excitement and my relief that all that pain of labor was over were short lived, as nurses were heard to say, “This may be your only chance to see your babies!” (They were very small and babies that size, in those days, did not live long). Again, unexpected but also unacceptable. We called our pediatrician and he went into action.

As days turned into weeks, my family and I waited patiently for “the girls” to gain weight, recover from jaundice, and be released from the hospital. That day came 6 weeks later. We all breathed a sigh of relief and brought the girls home. We began to build our lives together raising a healthy happy family of 6, as expected.

All mothers, as they watch their children grow expect that they will hit their growth milestones predictably—roll over, sit up, crawl, stand, walk etc. My sons did, why shouldn’t my daughters? But they didn’t. Being proactive and wanting my children to continue along expected lines of development, to the pediatrician we went. He suggested we see an orthopedist. His diagnosis: Cerebral palsy. Our reaction: Shock. But after the shock: Action. We would not take this lying down. We were educated parents. I had a Masters Degree in Special Education. My girls were going to grow up fine, as expected.

As they grew up, never once did I believe there were things they could not do. We never treated them as disabled children. We never told their brothers or their friends to treat them differently. I/we expected them to be part of an active family. I expected my girls, like my boys, to:

  • Dress themselves. Put on and lace up their own shoes (no matter how long it took). If you have to get up an hour early because it takes you an hour to lace up your shoes, so be it).
  • Walk (assisted or unassisted). The doctors told me my younger twin would never walk with crutches – her right hand was too weak. But she did, and at her sister’s wedding, she walked with a cane!
  • Do their chores.
  • Go to school. Of course I also expected they would go to the same school, which did not happen until their 6th year. ADA, Title 9, PL94-142 did not exist way back then.

Therein began the battle for education rights. Educators believed my daughter, who was in a wheelchair (for long distances) would have to be bused to another city instead of going to the neighborhood school that was within walking distance for her brothers and twin. All she needed was a bathroom with a grab bar in it to succeed, but they said, “No”.

Having little choice at the time, I sent her to that ‘other school’ expecting a good education. When this did not occur, I protested, wrote letters, talked to everyone who would listen until finally, the new superintendent of schools arrived. When I went to talk to him, fully expecting a confrontation, he said, “I don’t see any reason why she can’t come to our schools”.

The girls were back together. Family and community life continued as expected. I expected good grades — which they got. I expected them to participate in all aspects of their education, which they did, becoming involved in student government and theater arts, learning to ride and fall off their bikes, just like their brothers did. Sometimes they fell with their bikes, when we tied their feet to the pedals to keep them from falling off, but each time they got up and started again.

I believed that if my children put their minds to it, there was nothing they could not do. I know to this day they believe that. As their lives went on, each graduated high school with honors (as expected), each went to college, (rival schools) and I’m not sure if the separation was harder on them or me. They graduated from those schools with Masters Degrees, in the same field and are leading independent, productive lives, helping others with special needs.

They were able to do that because of my desire, and their will to be independent. I taught them life skills, which all of us need to make our way in the world. I taught them to be good citizens, to respect others and expect respect in return. I taught them to stand up (literally and figuratively) for themselves and not to let others (even if they are your brothers!) push you down. If they do, get up and push back.

Sometimes I think mothers of those with special needs expect too little of their children because “they aren’t like other children… they can’t do what other children can”.

I don’t believe that. My daughters remember a poem I placed over their beds when they were little that read, “I’m Special”. How true that was. They were special, not for what they could not do, but for what they could. They had lessons to teach us about taking life by storm and not letting anything get in the way of what you want.

I believe every mother should expect great things from all her children, no matter what their abilities. I did and I have never been disappointed.

About the author

Barbara Yauch has a Bachelor’s Degree in Education and a Master’s Degree in Special Education from Wayne State University in Detroit, MI. After teaching children with Special Needs for over 25 years, Barbara retired to southern Florida where she can be found ‘living the dream’ and enjoying the Detroit Tigers Spring Training in person. Contact Barbara at lycslp@gmail.com. .

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10’s by Lori Yauch

10’s by Lori Yauch

For our inaugeral column, we have selected Lori Yauch, a Speech Language Pathologist of over 20 years, practicing as an independent Consultant/Clinician in the Tampa Bay Area. Lori has a unique product that she would like to share with her colleagues, but in order to do that, she must first answer the 10 ‘no ifs ands or buts’. We hope you enjoy her responses as much as we did.

1. Cookie of choice for bedside swallow exams:

Lorna Doone

2. Preference for language testing BDAE or WAB:

BDAE

3. +/- or PICA for scoring:

Modified PICA (10 down to 1, but I forget what 2 is. I think it’s the same as 6, so why use it? You get more credit with 6, or maybe you just get egg roll. I can’t remember)

4. Muppets or dwarves for entertainment purposes only:

Muppets

4a. Favorite individual muppet or dwarf:

Elmo

5. Worst treatment moment of your career:

Any moment during my first job. I was a new grad and had to move away from home, living truly on my own for the first time. I lived in one state and crossed the border daily to work. My CFY Supervisor was selfish, unsupportive and certainly, ineffective as a teacher. I think it was her mission to find fault in every move I made, both in the clinical arena and in the building environment. I used a scooter to assist in my mobility and was written up for, among other things, the way in which I moved about the facility. By the end of 6 months I resigned. I heard later, she fell and was in a wheelchair for a time. You know what they say about paybacks! I moved on to greater and greener pastures. Years later I am a respected clinician, having supervised many students and CF’s and am here offering insights into our field Things really do have a way of working out.

6. Best advice you ever ignored:

I don’t typically ignore advice. However, there was a time when I was looking for bigger and better things. A friend suggested I come to her company, I considered it carefully and just as I was about to make the decision to move on, the company called and rescinded the offer. As it turned out, better offers came and when the time was right, I moved on.

7. Favorite, most reliable, and practical treatment strategy:

Masko Maneuver

8. Why SLP and not world domination?

SLP is world domination. One patient at a time.

9. Would you do it all over again exactly the same way?

Yes. If I hadn’t, I would not be where I am today. I learned from every experience. What I want and what I don’t. I have a good career balanced with a good life.

10. What one thing do you still want to do before your career goals are completely achieved?

Publish my manuscript. Movies and Music: A Clinician’s Guide to the Classic Movie Musical and Group Activity (which segues very nicely into the next question)

SHAMELESS SELF PROMOTION IN 30 WORDS (there actually is no word limit really so say whatever you want):

As clinicians in long-term care or adult rehab settings, we have all been faced with the necessity of providing group activities to our residents/patients. In an effort to come up with a new and innovative group idea, I decided to bring my passion for classic movie musicals and my job together. In conjunction with the Activity Dept. at the skilled nursing facility in Florida, where I was one of 3 speech pathologists, Movies and Music was established. In running this group I began to realize with the right material and right level of function, watching a movie which was once a sedentary activity, could be quite interactive. The interaction fostered increased communication, use of language, pragmatic skills, conversation and long term memory.

With this in mind, together with further observation that no group like this existed in any of the facilities I visited as a consultant, Movies and Music: A Clinician’s Guide to the Classic Movie Musical and Group Activity was born.

The guide is divided into 12 sections according to the calendar year and centers on a specific movie for a given holiday in the month (New Year’s Day, President’s Day, St. Patrick’s Day, etc). The films were chosen specifically for their ability to promote interaction.

The group size is generally 4 -10 patients with mild – moderate cognitive impairment. Diagnoses may include: Right/Left Hemisphere CVA, TBI, Dementia, Parkinson’s Disease or any other diagnosis at the Group Leader’s discretion.

Field testing completed during 2008-2009, yielded positive results with clinicians stating:

“ I highly recommend Movies and Music to any clinician working with individuals with mild to severe communication deficits….I look forward to being able to include this in my future plan of care at my facility.” Jane Fitzgerald House, M.S., CCC-SLP

“Assessment of the group dynamics indicated increased motivation, interest and curiosity which resulted in increased expressive language skills. … Group participants stated it was fun and interesting.” Lisa Mathers, M.S., CCC-SLP

Movies and Music: A Clinician’s Guide to the Classic Movie Musical and Group Activity is available for purchase. Please contact Lori Yauch at moviemaven1@verizon.net.

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What’s The Frequency (March 2010)

What’s The Frequency (March 2010)

By Marguerite Mullaney

My teammate in this venture does not really appreciate the name of my column. I find that the more she tries to get me to define the title, the more I identify with it. Frequency is, after all, about redundancy of actions within a finite time frame. Language like life itself is based on the certainty humans will repeat sequences of sounds and actions over and over. So, the more she asks the more I am certain my column is properly identified. I want my column to look at what we, as speech language pathologists do in our daily routines and ask, ‘why?’

I’m at that particular crossroad in my own professional and personal life. Why am I doing this work? Why am I working with this population? Why do I get up in the morning and drudge off from the home I love to spend a fair chunk of my waking hours in the service of strangers in somebody else’s sterile environment? Are these the why’s I want to be answering in ten years? What about twenty years? Dare I believe I have thirty years more to ask these questions?

So, what’s the frequency will be devoted to thoughts about what we do, what I do, and ask that simply impossible question: why?

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.

Read more ›