Last year at ASHA, I was really looking forward to a course by Kate Krival, Mary Casper and Paula Leslie called VFSS Lost in Translation. Last year that course was cancelled for reasons that are not going to be discussed here, but needless to say, I was disappointed.
Imagine my excitement when this course was offered this year at ASHA!! I don’t remember the session course number off hand, but it was incredible.
The session started off with a skit, reminding us all that we need to look at the ENTIRE patient, not just little bits and pieces and that we need to INFORM the patient. If we write a report to the treating therapist saying that the patient aspirated and needs to be NPO, what are we telling that clinician?? To me, when someone is made NPO it’s because nothing else worked. Not only that, but during the skit, the patient was told that everything was fine, then went back to the facility to learn that she would be made NPO.
First, look at the whole patient. Look at their cognition, respiratory status, current diet, medications, medical history, pneumonia, as well as their wishes. How mobile is the patient? Do any compensations work. Most important, what part of the swallowing function is NOT working as it is supposed to function?? Is there decreased tongue base retraction? If so, did anything help to strengthen it?? Is there decreased hyolaryngeal excursion? Did anything help to increase airway protection??
When you do the swallow study, did you check patient code status? Did you ask them what they want or what their wishes are? Think about it this way, you end up in the hospital. You’ve been eating and drinking with no problems. You don’t choke, you don’t have difficulty swallowing and you haven’t had pneumonia, ever. You do the swallow study and you are told that everything was fine. You somehow end up with a surgical consult for a PEG tube, all your water and food is taken away and you are told if you don’t get the PEG you will die of starvation. Talk about a slap in the face. As you sit there and think, but they told me downstairs I did fine. Nobody said anything other than the fact that I did fine.
As an SLP, we must look at how the patient functions. Don’t do one swallow and say, oh they aspirated, PEG tube. This DOES happen. Could a chin tuck help, thickened liquids, presentation by spoon, by straw, bolus hold then swallow. The possiblilities of evidence-based compensations are endless and who knows that something you try may actually work that has never been used prior!!
Talk to the patient. How does the patient know to trust you and your clinical skills if you can’t even describe what’s wrong with their swallowing function or how their swallow should look. Tell them they aspirated and what they aspirated. Educate the radiologist that penetration that clears in an elderly patient can be considered normal. We, as SLP’s working with dysphagic patients should understand the system and what we are treating. If you don’t understand the system, how it works and why, how can your patient ever trust your clinical judgement??
If you are writing a report for a patient you see that has dysphagia, you do the MBSS and recommend NPO status due to aspiration of thin liquids with no other explanations or descriptions, or trials, you just wasted time and money. You wasted the patient time, who, as an outpatient now has to wait at least 30 more days for another MBSS along with the fact that they are NPO with a PEG tube, which is known to reduce the number of swallows per day of saliva so they DO lose their swallowing function from disuse atrophy. You wasted Medicare money and in this day and age, how can we afford to do this?? You also wasted the time of the other SLP because how in the world can she/he possibly treat aspiration?? They don’t even know treatment strategies that might increase the function of the swallow and decrease the risk of aspiration.
We’ve all been there. We’ve all written the bad reports and completd the horrid, nightmare swallow study. The important thing to do is to learn, to become educated on better reports, better studies and then to utilize them in your facility. Learn from your mistakes and become a better clinician. Your fellow SLP’s and your patients will thank you. If you choose to ignore all this knowledge and wonderfully detailed information we are able to ascertain from an MBSS/FEES and continue to write reports stating aspiration, then shame on you!