acute care

★ Electrical Injury and Mild Traumatic Brain Injury

It's time once again for an edition of SLPs Blogging About Research! For information about this, or if you want to participate, you can find out more here.

Acute care speech pathology is a world all its own. Interestingly, it is not an environment conducive to therapy. Rather, I like to think of it more as a place for a lot of assessment, followed by maintenance and, naturally, more assessment. Most of the time, patients are too ill, or their injuries too recent, to begin to establish meaningful change in a therapeutic way.

This isn't to say that we don't have our own goals. Quite the opposite, actually. I remain a big believer that getting started early is the best way to begin on the road to recovery. Where I feel I can make a difference is to get in early and establishing some baselines for function. At the acute stage, there is often concern for evolving infarcts, or even the possibility of new ones. If a stroke is hemorrhagic, it doesn't make sense to push much for therapy because it's changing. Recovery, in general, requires medical stability, and at the acute stage stability is tepid at best.

An additional challenge of acute care is being able to recognize mild traumatic brain injuries. In the midst of the more severe cases, it's easy to encounter patients with mild TBI and feel like they're in relatively good shape. After working extensively with trauma patients, I've found that medical teams are often quick to dismiss head injuries if visible clots or bleeds are not seen on scans. Ask any neurologist or neurosurgeon, and they'll readily confirm that a clean MRI or CT does not necessarily indicate a lack of head injury. This is where SLPs come in handy on a multidisciplinary team.

The hospital where I work also happens to house a Burn Unit, which, as its name suggests, specializes in the care and treatment of burns. Several months ago, I evaluated a patient who was status post electrical shock injury with resulting brief pulseless electrical activity. Though the patient was what we affectionately like to call a "walkie talkie", I requested a consult out of concern for possible anoxic brain injury. I noticed some cognitive deficits in my initial evaluation, most prominent of which were attention and memory. When I brought this up to the team, a psychiatry fellow introduced me to a new world of mild traumatic brain injury, and one that did not necessarily involve any physical trauma to the head or brain.

The Neuropsychological Effects of Electrical Injury: New Insights By Pliskin et al.

The authors of this study note that, despite evidence, the following four assumptions remain common (as of the writing of the article) about patients with electrical injury:

  1. a more visible burn will indicate greater psychological difficulties
  2. low voltage exposures will not cause significant neuropsychological problems
  3. electrical injury patients who experience changes are not premorbidly psychologically stable
  4. electrically injured patients are faking their difficulties for secondary gain (i.e. workers' compensation)

The study focused on electrical injury peripheral to the head (no direct electrical contact to the head) and the source of electrical injury was a power source only (no lightning strike patients were included). Also, none of the patients studied had sustained a known head injury. They were separated into two groups: acute (seen within 3 months post-injury) and postacute (seen after 3 months post-injury). A control sample of electricians was used, and none had a history of prior electrical injury, neurological disease or lesion, head injury, or psychiatric illness.

The study was then split into three groups.

Study 1: Symptom Profiles

The participants and the control group were administered two assessments: the Neuropsychological Symptom Checklist (NSC) and the Beck Depression Inventory (BDI), and "[r]esults indicated that the EI (electrical injury) group had a much higher self-reported rate of phsyical, cognitive, and emotional symptoms" (143). In addition to physical complaints such as paresthesias (tingling), EI patients indicated cognitive difficulties such as difficulty with concentration, word-finding in conversation, memory, attention (feeling distracted), and "slower thinking".

Also of note, the authors point out that findings "were not statistically related to severitry of physical injury, voltage exposure, involvement in litigation, or previous psychiatric history" (143). What's more, they found that patients who were further post-injury actually reported more symptoms than the more newly injuried. "[T]he high frequency of specific cognitive complaints in the EI sample may be surprising, especially considering that no patient sustained a direct mechanical electrical contact to the head" (144). What's more telling, for me is their comment that "little is known about the pathway that electricity takes once it enters the body after perifpheral contact despite apparent hand to hand or hand to foot injuries" (144).

Study 2: Neuropsychological Function

The next step of the study was to determine if any objective data could be found to support the cognitive complaints noted in the first part of the study. They tested the following:

  1. intelligence (Wechsler Adult Intelligence Scale - Revised)
  2. learning and memory (Logical Memory and Visual Reporduction subtests of Wechsler as well as California Verbal Learning Test (CVLT))
  3. attention and concentration (Paced Auditory Serial Addition Test (PASAT), Stroop test, and trailmaking test)
  4. motor function (grooved pegboard)
  5. depression screening (Beck Depression Inventory)

The study found significant differences, with "poor performances on measures of attention and concentration, motor speed/dexterity, and memory performance... [and] visual memory performance in particular was worse in the EI group, especially in initial acquisition of new information" (145). Once again, the study also found that postacute patients had even lower scores than acute patients.

Study 3: Longitudinal Outcome

The study found that these symptoms and functional deficits could be present for years after an accident, with an average report of 3.9 years. Further study is indicated to better understand these long-term implications.

The study concludes almost more questions than it started with. The biggest one: "why are patients who were seen postacutely up to five years after injury apparently worse from a psychological and nueropsychological standpoint than patients who were evaluated acutely?" (147). The authors question if it takes time for effects to truly become apparent, or if these patients represent only a small subset of electrical injury patients. Further studies are indicated.

The Takeaway

I have to thank my psychiatrist colleague for sending me this article. Even though the focus is from a psychological perspective, I found the information immensely helpful and a definite asset to my clinical foundation. I appreciate more than ever how vital it is to be part of a multidisciplinary team.

Though electrical injury is thankfully a relatively rare diagnosis in my practice, I feel more prepared to work with patients and having this information will go a long way for patient and family education. For example, with the patient that sparked this discussion earlier this year, I was able to provide the patient and family with information and resources in the event that difficulty might arise following discharge.

Article Citation

Pliskin, Neil H., et al. (November 1999.) The Neuropsychological Effects of Electrical Injury: New Insights. Annals of the New York Academy of Sciences, vol. 888, pp. 140-149.

★ Oral Cares For Days

SLP colleague and #SLPeeps twitter friend Rachel Wynn recently rallied the community of SLP bloggers to write about research. The mission? Taking the time once a month to read a research article and then write a review about it.

Having recently attended ASHA’s Dysphagia in Older Adults online conference, I have had a lot of research on my mind. As with any good continuing education, I walked away from the conference with far more questions than I had when I started it. Since then, I have found myself thinking often about different presentation topics, and how they fit into my professional life.

One topic that stands out to me, in particular, is that there is a lack of adequate research in acute care. And it seems that my conference wasn’t the only one during which this topic arose.

I’m finding myself in an interesting position, profesionally speaking. It has been now two years since I earned my CCCs, and at the moment I feel like all I want to do is pause, pull out all my textbooks and notes, and re-learn everything I ever studied in school. My perspective has shifted so significantly since I was a student; I find myself thinking about everything on a much larger scale than I ever imagined, and there’s so much I want to know.

Having a goal in mind is always nice, so it was timely that Rachel suggested this blogging endeavor. It’s given me a little bit of direction, something I think I sorely needed.

An Article: Nay, a Review

One of the presentations from the online conference was called Oral Hygiene in Older Adults: Complications, Assessment, and Care, and was presented by John R. Ashford, PhD, CCC-SLP. In 2012, I joined two Special Interest Groups, and when looking for articles for this project, I happened to perusing the “Perspectives” resources for SIG 13 (Swallowing and Swallowing Disorders). John Ashford had published an article in 2012 called Oral Care Across Ages: A Review.

Personal Bias

As an acute care SLP, I find that many of the patients I work with have, for lack of a better descriptor, disgusting mouths. This could be do to any number of factors: alcohol or drug abuse, prolonged intubation, and radiation therapy for cancer, to name just a few. When I work in the ICU, I have a tendency to start working with patients early. That is, I like to evaluate them before they might be ready to start eating. Not only have I found it beneficial in terms of being able to really gauge patients’ progress, but it also allows me to do my part to help advance them to feeding readiness.

I can’t quite recall when I started to say it, but I noticed recently that I have a little catch phrase I seem fond of sharing with patients and families: “If your mouth doesn’t feel good, then the rest of you doesn’t feel good.” It’s a simple observation, but I feel it’s a powerful one. It occurred to me at one point when I was sick; the combination of mouth-breathing and that filmy yet dry coating of my tongue and palate seemed to compound my illness.

The Mouth At Work

How does the mouth really work? It turns out, it’s not all that different from the rest of our GI tract. We’re very fond of probiotics these days, and we often discuss the idea that within our bodies lies a veritable ecosystem of bacteria. Our oral cavity, as the “beginning” of our GI tract, has its own ecosystem. John Ashford breaks it down nicely: “the oral cavity is covered by a protective mucous membrane, serous fluids, and mixtures of microorganisms, or flora, comprised of bacteria, viruses, and fungal species.”

The fancy term for this is biofilm, and it covers the surfaces of the oropharynx and teeth. “These coatings benefit the oropharynx by stimulating the immune system to protect surfaces against colonization and infection from invading microbes and to stimulate certain nutritional and digestive functions.” It’s like a naturally-occurring vaccine: a little bit of exposure keeps our immune system on the ball. The flora also function, as they do in our intestines, to help break down nutrients so that our bodies can extract them and use them accordingly.

Breakdown

While we are able to manage exposure to bacteria when healthy, illness of any kind leads to susceptibility. Poor oral health coupled with illness can leave one with greater colonization of bacteria and fungi, which, if aspirated, has the potential to cause pneumonia.

Many of the patients I encounter have poor oral care at baseline, which results in lost and broken teeth, and many of them have full or partial dentures. “[T]he acrylic and silicone materials used in denture and denture-lining construction provide ample surfaces for bacterial attachment.” As a result, proper denture cleaning is a must in addition to oral cares. Another point to consider, which I hadn’t before, is that “dentures that fit closely to mouth surfaces reduce salivary cleaning” (emphasis mine). We swallow routinely throughout the day, so basically the flora in our mouths are not permanent residents.

In his presentation for the Dysphagia in Older Adults Conference, John Ashford explained that saliva contains certain sugars, and it is those sugars (rather than oxygen) which the pathogens in our flora live on. Saliva, in a sense, acts as both an incubator (maintainer of moisture to provide an environment for flora to thrive, relatively speaking) and a lubricant. The “serous fluid [found in saliva] is rich in antimicrobial substances… [which prevent oral pathogens] from attaching to and colonizing the oropharyngeal surfaces, thus preventing oral infections.”

Oral Cares

Where does this leave us as SLPs? There are different schools of thought: some feel that oral cares responsibility lays with nurses and techs. It makes sense, given that they are usually the ones present 24/7, while we SLPs can only be present intermittently. Any SLP who has worked in a medical setting, be it acute, LTAC, SNF, etc., is likely aware that oral cares are often neglected in the face of other, seeming more pressing, issues. I’ve also found that my emphasis and perspective of the importance of good oral care is not always shared by others; this isn’t a bad thing, necessarily, but I think the nature of increasing specialization. It’s why being part of an inter-disciplinary team is so important: I can develop a plan, emphasize its importance, and encourage the team to follow the plan to ensure the best patient care.

Ashford cites a number of studies which show that “tooth brushing is strongly supported over use of foam swabs with hospitalized and nursing care patients”, as “toothbrushes were substantially better at removing plaque”. When I provide oral cares, I often begin with a swab, as I have found it more effective to remove dry oral mucosa that may be coating the tongue, teeth, and palate. Once I am able to clear the oral cavity, I then go back to brush properly. In the event that someone’s mouth is particularly messy, I like to provide thorough cleaning before initiating any PO trials. It has the benefit of not only helping the patient feel better (and optimize their chances for success), but it can also serve as a nice way to increase level of arousal in somnolent patients.

Moving Forward

I appreciated this article, as well as the conference lecture, as an excellent starting point. I have been looking into further into tools like the Oral Health Assessment Tool (OHAT) and educational tools like “KISS” (Keep it simple, staff) Basic Oral Care for caregivers.

I hope to increase my knowledge and plan to implement oral care plans as part of my recommendations. I hope to help my department increase awareness of the importance of oral care and how it can benefit patients. I hope to increase the availability of artificial salivas (such as Mouth Kote) for critically ill patients suffering from xerostomia.

I would also love to start collecting more informal data so that I can monitor patient progress compare efficacy of the treatments I may provide.

As I wrap up this post, I’m struck by how much I still want to know. Many of the resources Ashford provided in his article are from outside professions, such as dentistry and other medical publications. I am reminded that, while we have wonderful resources available within our own organization, sometimes collaboration with other professions can yield a whole other world of applicable information.

I look forward to continuing to explore new territory. I hope to keep finding reasons to question what I know, and to always work to broaden my horizons.

Article Citation: Ashford, John. (March 2012.) Oral Care Across Ages: A Review. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), vol. 21, pp. 3-8.

(Aside: Comments are open. I welcome dialogue, new ideas, and cool ways to rethink all these things. Thoughts?)

★ Curious Diagnostics

One thing I love about working in the acute hospital setting is being part of the medical team and aiding in the process of differential diagnosis. In some ways, working with people with swallowing disorders is its own process of differential diagnosis. SLPs are presented with a patient complaining of difficulty swallowing, and it’s our job to narrow down what type of difficulty that is, and how we might help remediate it. This applies to more than swallowing, of course. Acquired or developmental speech and language disorders, fluency disorders, and cognitive communicative disorders are all things we assess and can potentially treat.

During any given day or week, I encounter a variety of diagnoses. I’ve recently taken to writing them down, as I have been curious about what I encounter and doing research as I am able. I will present them here, in no particular order or sequence, but rather as I encounter them and/or see fit.

The more I work in this setting, the more curious I have become about the human body and how it works. I’m looking forward to learning more and seeing where this journey takes me.

★ There will be days like this.

Sometimes I have to remind myself that not every day will go according to plan. Things won't always go my way in spite of all my hard work. Sometimes I have to remind myself that acute care can be a scary place, and that I might witness a patient who appears to be doing well experience sudden onset hemiplegia, dysarthria, and aphasia from a stroke in the middle of an evaluation.

Sometimes I have to remind myself that it's okay to take a step back, and catch my breath.

Sometimes I have to remind myself that I'm only human, and so are my patients.

I know there will always be days like this. I just have to remind myself that it's perfectly okay not to like them.