The Patient

I know.  You hear all the time about the importance of instrumental assessment and how vital instrumental assessment is in your plan of care.   You get all the research, you read all the articles and posts about instrumental assessments.   

There are still people out there totally and completely confident that they are able to tell when a person aspirates or does not aspirate by use of a Clinical Swallow Evaluation alone.

I am completely in agreement that the Clinical Swallow Evaluation is critical in the assessment puzzle.  Like any good investigator, you have to fill in all the pieces to make the picture as complete as possible.   

I’m going to tell you a story.  All identifying information has been changed to protect the identity of the patient.

Harold is 87 years old.   Harold was in the hospital for a second stroke when the Speech Language Pathologist was called in for a bedside evaluation.   Harold also has COPD but is otherwise fairly healthy.   Harold has severely impaired with expressive language due to aphasia and nursing was concerned because Harold choked when they attempted the Yale Swallow Protocol.   The Speech Pathologist came into the room, armed with crackers, pudding and water.   Harold was asked to complete a series of 1 step directions and was unable to follow most directions at the time.  Harold had a labial droop on the right side, indicating CN VII (Facial Nerve) damage.

Harold was given an ice chip with no difficulty noted with swallowing.  When given a drink of water Harold choked to the point that he was unable to catch his breath and his face was turning different shades of red.  When Harold recovered, he was given a bite of pudding and seemed to swallow the bite of pudding without difficulty.  Harold also was able to use his tongue to remove a small amount of pudding that remained on his upper lip.   The second bite of pudding resulted in choking again.

It was recommended at that time that the SLP would return in the AM to reassess patient status and determine if patient would be appropriate for a Modified Barium Swallow Study (MBSS).  Modifieds can only be performed on specific days as the radiologist is not on site every day.

Patient was re-assessed and it was determined by choking that patient was still aspirating and not ready for MBSS at this time while in acute care.

Patient had a G tube placed for nutrition and hydration and was sent to acute rehabilitation.   While in rehab for several weeks, patient was seen by the SLP.   It was determined by Clinical Swallow Evaluation that patient was not able to manage his secretions and no instrumental assessment was completed while staying in acute rehab.  

When Harold was sent home, he was recommended for Home Health Services.    Harold had not eaten in nearly FOUR months and due to the aphasia was unable to state what he had been doing in therapy.   During his evaluation, Harold was given a pureed consistency to try.  At this time, Harold had difficulty maintaining saliva in the oral cavity, due to continued right sided labial droop/weakness with poor lip closure on the right side.  Harold had to keep a towel nearby.   Harold swallowed the pureed consistency with no signs of difficulty other than some mild pocketing on the right side which he cleared easily with cues.   Harold ate the entire portion with no coughing.   

Harold went to the doctor later that day for an appointment who scheduled Harold’s first MBSS since his stroke for the next day.

Harold was placed on a pureed diet with nectar thick liquids and was soon upgraded to thin with mechanical soft and eventually regular food.

Harold was happy and started communicating more.  Harold no longer needed a towel because he had no further issues with drooling, other than occasional anterior loss of bolus with thin liquids on the right side due to mild labial weakness.   Harold was so happy to be eating and started improving in all areas of therapy.   

Moral of the story:  Harold wasn’t able to tell the acute care SLP that he frequently has choking with liquids and without due to his COPD.   The choking seems severe when it happens and his face will turn 50 shades of red when the coughing happens.  Harold has had no respiratory compromise with any of the choking events.   Sometimes our bedside ears deceive us and we need to see what is happening in the pharynx to be able to create the most effective plan of care for our patients!

6 thoughts on “The Patient

  1. Hi,
    I am a student at speech and language therapy.I have a guestion.What are the standardized dysphagia assessment tests. Could you help me ?

  2. First of all, I’m happy for Harold! This made me think of the article a couple Leaders ago about accessing healthcare with communication difficulties. Of course I agree with the importance of seeing what is happening but also an important lesson in not becoming so focused on dysphagia we miss facilitating communication at every stage!

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