If you are like me, you are inundated with social media advertisements for various certification or continuing education courses.

The question is…..which do you choose?

We most certainly can’t afford to attend every course or obtain every certification.  So how do we figure out which courses are worth our time and money?

1.  The course is ASHA approved for CEUs-Be aware.  Just because the course provides you with ASHA CEUs doesn’t necessarily mean that it is a good course.  While courses are required to be peer-reviewed for ASHA, that doesn’t mean the course is the cream of the crop.  ASHA also does not endorse any specific treatment or tools.  We still have to be conscientious learners.
2. The course offers “fast” results-I have had the very few patients that met their goals in a short amount of time.   When we work with patients with dysphagia, we are typically working on changing muscles.  This involves strength, coordination and timing.  I can’t go to the gym and strengthen my arms in “just a few sessions”.
3. Watch the evidence base-A new course can have 150 different references to “support” it’s use.  Read the evidence.  Some may not even be related to the technique you are learning.
4. Does it really make sense?-The presenter may have you convinced by the end of a course or even through the advertisement that this new technique works wonders because of x, y, z.  Sit down and think about this.  (This is where our critical thinking caps must be ready to go!)  Does this technique make sense?  If I have a patient concentrate on working their knee, is that really going to change the swallowing system?
5. Use your social media-Post in Facebook groups, use Twitter, Pinterest or even the ASHA SIG groups to question new courses and techniques.  You shouldn’t have to shell out thousands of dollars on a technique that doesn’t work.  You can absolutely keep an open mind to new techniques but maybe others in these forums can help you problem-solve why these techniques may or may not work.

We all work hard for our money and time is a precious commodity.  Choose continuing education and new techniques with care and always hold the welfare of your patients paramount.

What are some courses you have really enjoyed or wish you would have skipped?

What do you think would be the best resource to use to share and look up quality, evidence-based continuing education courses?

I would first like to thank Northern Speech Services for sending me this wonderful reference to review!

If you haven’t yet had a chance to take a look at the new Pocket Reference from Northern Speech Services, you should!  This is a great reference tool for working with patients with trachs.
First, the guide is not much bigger than my iPhone 6.  It very easily fits in my scrub top pocket.  The pictures are large and very visually appealing.  Each page consists of some text but is not too much to read.  It is truly a reference tool.

The book consists of the following sections:  Basic Tube Anatomy, Selection, Cuffs, Brand Identification, Code on Neck Plate, Sizes, Speech, Talking Trach Tubes, Speaking Valve Identification.  Each section consists of pictures and texts to aid in the identification and decision making for Trach tubes and speaking valves.  

Whether a seasoned or new clinician working with patients with trachs, this is definitely a guide worth the money!

Find the Quick Pocket Reference for Tracheostomy Tubes and Speaking Valves here.  

Thickened liquids have had a lot of publicity lately in social media.  They’ve been a large part of dysphagia management.  Sometimes, it can be argued that the use of thickened liquids occurs more frequently than other compensation or management techniques.

• “Texture modification has become one of the most common forms of intervention for dysphagia and is widely considered important for promoting safe and efficient swallowing.”  (Steele and Miller 2010)

Often, products or research is aimed at reducing the use or need of thickening liquids.  The Provale cup is one such product that only allows the patient 5-10 ml per drink, which may or may not be a safer amount of thin or nectar thick liquids.

There is a lot to look at when looking into thickened liquids.  The physical cost is definitely an issue.  Thickener is not cheap.  My friend Vince Clark calculated the cost of pre-thickened liquids and posted the following on Facebook:

When we look at the cost of Thickened liquids:

• Per Day: 9 x .34 = $3.06
• Week: $21.42
• Month: $85.68
• Year: $1116.90

These are the costs of a single organization.   An individual purchasing thickener may pay double.

We also need to look at how thick we’re recommending for our patients.  Many times and research back that maybe nectar thick is enough.   Dr. Leder looked at patients that aspirated thin liquids and found that these same patients had 100% successful swallows with both nectar and honey thick liquids indicating that nectar thick may be adequate to promote safe swallowing.  (Leder et al 2012)

There has been research leading to the fact that maybe we shouldn’t thicken liquids.  Dr. Logemann et al found honey thick liquids were the most effective in eliminating aspiration when compared to nectar thick liquids and a chin tuck.However, when aspirated, honey thick liquids had the most significant impact causing pneumonia, longer hospital stays or death.  (Protocol 201).

There are times patients are seen for a Modified Barium Swallow Study (MBSS), they penetrate with both thin and nectar so they are placed on honey thick liquids.  Perhaps the debate should not be an all or nothing, thickened liquids or no thickened liquids, but look at the whole patient and make the decision with them.  Always consider those patients that aspirate thin liquids during the MBSS, return home, continue to drink thin liquids and never die from aspiration pneumonia like we sometimes teach them will happen when they aspirate.

My interpretation of this research into my very real daily job is that I need to consider the whole patient and that some patients just need those thickened liquids.  They’re not going anywhere anytime soon.

In fact, thickened liquids can be great therapeutically.  Dr. Bonnie Martin-Harris has done quite a bit of research while developing the Modified Barium Swallow Impairment Profile (MBSImP) and has found that using a nectar consistency during the Modified Barium Swallow Study (MBSS) there is more significant pharyngeal movement during the swallow.  There are also studies looking at how adding “weight” to the bolus can be an effective therapeutic strategy.

We need to be careful in interpretation of research.  Just because an article came out that says not to use thickened liquids at all, don’t go and throw out all your thickener.  (Wallace, this article, 2016).

The cost is not only monetary, but also in our patient’s health, satisfaction and quality of life.  We all have or have had that patient that just really doesn’t mind thickened liquids.  They drink the liquids, they may not be turning cartwheels with thickened liquids but they tolerate them.  Some patients know it’s short-term and once they rehabilitate their swallowing function they may be able to resume thins.

We also have or have had those patients that just outright refuse thickened liquids.  They don’t like the texture or the consistency.  This may be the patient that says, “I know I need them but they taste like snot.”  (A former patient on thickened liquids circa 2011.)  This may also be the patient that refuses to follow your recommendations or just stops drinking all-together.

There always has to be a balance and a consideration for hydration, overall health, respiratory health and patient satisfaction.  I’m not talking the survey the patient gets and rates you on a scale from 1-whatever.  I’m talking about their everyday, I’m happy with my life satisfaction.

Always look at your patient as a whole.  Look at their respiratory system, their overall health, history, cognition and if able create a plan with that patient.

I have completed many MBSS’s with many patients over my years.  “Remember, the person is here because they have been having difficulty with their swallow.  I’m guessing this isn’t the first or last time they have or will aspirate.”  (Wallace at every MBSS when the radiologist is ready to quit because the patient aspirated.)

Remember those elders at the SNF that are put on thickened liquids and remain on honey thick liquids for the rest of their days.  These may be the same people you say wandering the halls, stealing drinks at the water cooler, stealing drinks from the tables in the dining room or sneaking drinks from the bathroom sink.

Steele, C. M., & Miller, A. J. (2010). Sensory input pathways and mechanisms in swallowing: a review. Dysphagia, 25(4), 323-333.

Robbins, J., Hind, J., & Logemann, J. (2004). An ongoing randomized clinical trial in dysphagia. Journal of communication disorders, 37(5), 425-435.

Leder, S. B., Judson, B. L., Sliwinski, E., & Madson, L. (2013). Promoting safe swallowing when puree is swallowed without aspiration but thin liquid is aspirated: nectar is enough. Dysphagia, 28(1), 58-62.

June is Dysphagia Awareness Month.  A month dedicated to a disorder that most have never heard of but comprises 80% of my work.  It’s not even in my title, so what the heck is dysphagia?

What is Dysphagia?

If you Google dysphagia, you get this:

(I love this picture from Simply Thick!)

Often, I am asked what I do for a living.  If I say Speech Pathologist I get that look of “what?”  If I say I work in a school, it’s assumed that I’m a teacher and if I say I work in a hospital, it’s assumed that I’m a nurse.  When I say I work in both setting, there’s mass confusion.

This month kicks off Better Hearing and Speech Month for Speech Language Pathologists (SLPs).   If you’re not sure what an SLP does, well, we do A LOT!  If you are looking for a job with a great deal of variety, plenty of learning opportunities and flexibility, well, this is a pretty good start.  **Disclaimer:  This post is information an SLP will already know and was intended for a variety of readers.**

An SLP can work with people from newborn to elderly.  We work with people that were born with cerebral palsy, developmental delays, autism, Down Syndrome (along with a number of other syndromes) and with acquired speech, language and swallowing problems due to stroke, Parkinson’s, brain injury, cancer, and a variety of other diseases or traumas.

We work with articulation (production of speech sounds), language, voice, cognition (memory, problem solving, attention), reading, social language, executive functioning, motor speech and swallowing.

An SLP goes to school for 6 years, as a Masters Degree is required.  Many SLPs go on to get a Doctorate.  SLPs work in school systems, nursing homes, rehab facilities, home health, First Steps, hospitals, NICU and universities as well as private clinics.  Some SLPs will even go on to research certain areas such as swallowing to help SLPs better understand the physiology, anatomy, assessment and treatment techniques.

Swallowing and Swallowing Disorders is my area of expertise.  I even took the extra step(s) to obtain my Board Certification in Swallowing and Swallowing Disorders (BCS-S).   During the process I had to demonstrate that I not only understand swallowing and swallowing disorders, but also go above and beyond to educate others.

Dysphagia (swallowing disorder) seems to be an area in our field that has very little understanding and even less recognition.  Dysphagia is becoming one of the primary assessment and treatment diagnoses in the medical field.  Some schools even offer dysphagia therapy for school-aged students.

You may wonder what an SLP can possibly do with a swallowing problem.  The SLP is the person that assesses the swallowing difficulty.  Assessment may be completed through (most commonly) a clinical evaluation, Modified Barium Swallow Study (MBSS or also known as a Videofluorographic Swallow Study VFSS) and/or Flexible Endoscopic Evaluation of Swallowing (FEES).

Treatment may happen in the form of diet consistency alterations, compensatory strategies or rehabilitative exercise.

I often ask myself, “What am I doing for my profession?  How am I helping?’  Part of my job has been education.  I have developed webinars and taught live seminars to help further the knowledge of others through evidence-based practice.  I keep current in evidence and continuing education.  I use this blog for education, not only for clinicians but also for the general public.  I use Facebook groups and Twitter to share information.  I have authored/co-authored 3 apps with Tactus Therapy and SmartyEars.

What do you plan to do to share knowledge regarding our wonderful field??

Educating others is a huge part of what we need to be doing.  Let everyone know what we do and why we do it!!

Picture from:  http://www.autismafter16.com/article/01-18-2013/always-advocating

If you are on Facebook in any of the SLP medical-based groups, you know the word of everyday is advocacy.  There are too many stories of Speech Language Pathologists not able to get instrumental examinations for their patients with dysphagia because of the cost.  People are losing their jobs for not maintaining 90% productivity.

We all talk about advocating for the needs of our patients.  At the end of the day, the patient is the one who is not receiving the service they were promised.  At the end of the day it’s the patient’s life that we’re playing with.

How many times have you been in a facility and heard “Oh, you’re just speech.”  I have.  Yes, I’m just speech.  Yes, I have a very important job of making sure that a patient is safe with a diet, rehabilitating the patient’s swallow to make them safe with the consistency they desire, setting up a cognitive program so that person can function as independently as possible, making sure oral care is complete and appropriate to reduce the risk of pneumonia.  Just because I’m not the person that is going to come in and put your patient back into the bed doesn’t mean my job is not important.

It is true.  We do need to advocate for instrumental assessment.  Otherwise it’s a guessing game.  At ASHA 2015, there was a great session on instrumental assessment vs. bedside assessment by Coyle, Leder and McCaullaugh.  One of my take-away messages:  “Once the mouth is closed, everything is inferred.”  “The clinical bedside exam is a series of pass-fail screens.”  “We need more than a cough to determine that a patient might aspirate.”  “No part of bolus flow or the pharyngeal phase can be assessed without instrumentation.”

I wish that every professional with which I work could have attended this course.  I feel like 80% of my job in the acute care hospital is education.  I take many opportunities to educate staff that I, in fact, cannot determine if the patient is aspirating or has aspiration pneumonia during a clinical assessment.  I may have a good idea that they are, but there is no way to say for sure.

I educate staff that a chin tuck, may indeed be the contributing factor to aspiration and may not help the patient after all.  Instrumentation is required to determine if the chin tuck may or may not be an appropriate strategy for the patient.

I educate staff that the gag reflex is NOT present in every person and that it is not a reliable predictor of the ability or inability to swallow.

Sometimes we advocate just for the use of instrumentation.  My friend Shareka lives in Barbados.  She had the equipment available for a modified barium swallow study, however she had to advocate to use it and FINALLY was able to complete her first MBSS.

Here in the United States many of us advocate for FEES assessments with and without success.  We have to prove outcomes, cost effectiveness, etc while sometimes our therapy counterparts are able to purchase large equipment without the same hassle.

We have to stand up at some point and let other medical professionals know that what we do matters.  We’re not “just the speech therapist” and that we’re more than a few service-based codes.  This will not change if we all sit back and hope ASHA or our state organizations do this for us.

Do you need some inspiration in advocating for instrumental assessment?  This post was put together by Vince Clark and Kate Krival and approved by members of the Dysphagia Therapy Group Advisory Board.

“Often SLPs comment on this page about how testing (both Modified Barium Swallow Studies – MBSS and Flexible Endoscopic Examination of Swallowing – FEES) is openly discouraged or “not permitted” by administration. While this occurs in all settings, it seems that skilled nursing facilities tend to be the setting where this occurs most often. The topic comes up so frequently that the admins on this board feel we need to address it. It is worrying that this trend seems to be so pprevalent throughout our work environments and it is particularly troubling when it is discussed here that the leadership often encouraging “no testing” or making inaccurate claims about what ASHA considers “best practices” are SLPs themselves. In order to give those in the field easy access to ASHA policies and guidelines, we present the following statement and resources.