medical SLP

◆ Looking back and moving forward.

2015 started out as a year of uncertainty for me: I was leaving my job of over three years to venture out into the unknown. I was stressed out, exhausted, and not sure how to proceed. I had tied much of my professional identity to being an acute care SLP, and the thought of changing was incredibly daunting. Would I be able to jump into the world of rehab and know what to do? Would I like it? Would I be able to make ends meet?

In the midst of this large professional shift, my family was having its own challenges. My mom was in the middle of chemo and radiation treatment for cancer, and making sure I was present for my parents was very important to me.

This blue bear served as a frequent reference point for me when trying to navigate the Denver convention center at #ASHA15.

This blue bear served as a frequent reference point for me when trying to navigate the Denver convention center at #ASHA15.

When I first wrote about this change I had no idea what all these changes would look like. As these things so often seem to go, nothing goes according to plan. Because the credentialing process for insurance takes a very long time, and because I was the very first SLP at the private practice, I had to find other work while waiting to be approved to provide services in that setting.

To sustain myself in the meantime, I picked up a PRN position in home health. This was (and is) a fascinating and challenging position, and was a wonderful way to rebuild my therapy skills. I also picked up freelance interpreting work. I was a sign language interpreter before becoming an SLP, and have long kept up a small handful of hours on the side. Picking up more hours was a helpful change of pace, and afforded me a nice variety to my work.

With all that said, here's some things I've learned in 2015 that I believe will make 2016 an even more exciting year.

The Denver convention center was an easy walk from the hotels and the sunny weather made for a very pleasant convention experience. 

The Denver convention center was an easy walk from the hotels and the sunny weather made for a very pleasant convention experience. 

Trust those instincts.

From figuring out how to proceed in therapy, to knowing what kind of work to accept, pay attention to that little voice especially if it expresses nervousness. In the process of my hiring for both the home health and the outpatient positions, I noticed a fair amount of disorganization that left me nervous, so I accepted only PRN positions to afford me more flexibility in that environment. As a result, I've been able to be flexible with my hours and make sure that my caseload is manageable.

Learn new things.

It's no secret that I enjoy conferences. They are in part a social experience for me, since it's a chance to see colleagues from around the country (and world). Meeting new colleagues is equally important. The interaction with my fellow SLPs and audiologists allows as much opportunity to learn as the workshops themselves.

This year, I stepped out of my comfort zone and attended some sessions in areas which I don't currently treat. For example, I attended a session about transgender voice therapy, and it turned out to be one of my favorite sessions of the entire convention. When thinking about why this was, I realized that it was because I got to think about therapy in a different way for a change. Also, one of the topics emphasized in the talk was principles of motor learning, which is a hot topic in the areas of dysphagia and motor speech. Hearing it discussed in new ways, by SLPs who talk about their work differently than I do, was a fantastic way to really start to get a better grasp of the concept and understand why it is so vital to therapy. On top of that, it helped me learn about an area I have interest in, but not experience or training. It may help open new doors in the future, and in the meantime has already helped make me a better clinician.

The main entryway in the Denver convention center. 

The main entryway in the Denver convention center. 

Do the right thing.

Ethical challenges come in all shapes and sizes. It may be a company that accepts more patients than they have staff to accommodate. It may be an employer with unethical billing practices. It may be pressure to see more patients than you are able to handle.

In the past year, all of these situations have presented themselves to me, in varying degrees of seriousness. It proved to be to my advantage to accept work only on a PRN basis, as it has afforded me more control over my time and my work. I do not accept new patients unless I know I can commit to providing their treatment consistently. Having become all too familiar with burnout, I recognize and honor my limits, and always remind myself that if I don't take care of myself, I'll be a less present, and therefore less effective, clinician for my patients.

I love windows that move up tall buildings, and appreciated all the light they brought to the convention.

I love windows that move up tall buildings, and appreciated all the light they brought to the convention.

Move forward.

For me, 2015 was a chance to reboot. Though I wasn't looking for it at first, change found me and reminded me I needed it. Challenges presented themselves and I found strength I didn't know I had. I re-invented myself in ways I hadn't imagined I could, and in the process of learning about myself, I found myself growing both personally and professionally. My patients were a big part of that growth, and have helped me to identify new goals for myself.I never used to set goals for myself. In my last job, we had an annual performance review, and I always had a hard time thinking about what I wanted to accomplish in the next year. "I just want to do my work and do well at it," I used to say. This year, I find myself having tangible goals I want to accomplish. Among these, I want to more readily identify ways to target and help my patients meet their goals. I want to start a business and learn to establish contract relationships so I can be more flexible and mobile with my services. In this vein, I want to write about what I learn, both so that I can hold myself accountable with my goals, have a way to look back on what I've learned, and also that others may learn from my experience (both the good and the bad).

Cheers to 2016. Let's make this year an awesome one.

★ 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?)