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What Would You Do?

I would love to share a story with you. 

Now keep in mind, I’ve been an SLP for a lot of years and feel that I do a pretty good job.   Sometimes, I may even get a little over-confident in my skills and have to examine what I’m doing.

Let’s talk about a patient I’ve had.   All identifying information will be withheld. 

This person was referred after a family member was concerned with increased choking with food and drinks.   This patient has a history of dysphagia, which had resolved. 

I get the call to go in and go in prepared for an evaluation. I did everything I would normally do in an evaluation.

I did a cranial nerve exam which all the cranial nerves seem to be intact. I had the person eat and drink while I observed. I even palpated the larynx to see what I could feel. Everything seemed to be quite normal.

I have to do vitals for home health so I went ahead and got out my pulse oximeter to see if there is any change in the person’s sats. They were able to drink some water with no change in 02 saturation.

Everything seemed to check out pretty well however the family was still very concerned, so just to cover my bases and to make sure that I hadn’t missed something I requested a modified barium swallow study.

Now imagine my surprise when I get the report for that swallow study and find out that this person’s actually aspirating multiple consistencies.

The person has timing issues with laryngeal elevation and closure and with oral containment prior to the swallow.

I mean really how can that be?

There was no change in O2 sats for me. The larynx felt like it was moving pretty well. Cranial nerves seem to be intact and functioning.

Where did I go wrong?

I didn’t. I realized my limitation without visualization. I have read my research and know that O2 sats and palpation is not always accurate.

I did right by my patient and pushed for instrumental exams.

I had push-back at first. Do you really need an instrumental? Can’t you just treat? When I told the company I need the instrumentals or I’m referring patients to another company, they started approving my requests.

Do right by your patients.

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3 Reasons You Should Never “Fake it Till You Make it” in Dysphagia

 

I really don’t know where the phrase “fake it till you make it” came but it’s one phrase that absolutely makes me cringe in relationship to dysphagia.

Don’t get me wrong.  You should always go in confident in your skills.  How can you possibly be confident though in skills you don’t possess?

The scary part is, with dysphagia, if we don’t know what we are doing, but go in to diagnose and treat on the “fake it till you make it approach” we can play a key role in the person’s death.

Not necessarily that the person even chokes on something.  When we change a patient’s liquids and thicken the liquids, the person can then experience dehydration, sepsis, UTI or a multitude of other effects.

So let’s get to it.  The THREE reasons why you should never fake it till you make it in dysphagia therapy.

Reason One

It’s actually against our code of ethics provided by ASHA.

“Individuals shall not misrepresent their credentials, competence, education, training, experience, and scholarly contributions.”

When we “fake it” we are actually telling patients that we are competent in an area that we may not have a clue and misleading that patient.   Ideally, we should help that patient find a competent clinician if you do not feel that you fit that bill.

Reason Two

How can you assess and diagnose what you don’t know?

Yes, we diagnose dysphagia.  This is the reason we are Speech Language Pathologists in the US.  We are able to diagnose a range of speech and swallowing related disorders.

If you don’t understand the normal swallowing process and know the deficits, how can you possibly diagnose dysphagia?  Did you know that when a diagnose is given to a patient, that diagnosis stays with the person.

Misdiagnosis often leads to inappropriate diet changes, unnecessary therapy services and possibly secondary issues that can arise from those inappropriate diet changes.

I mean, do you really know any person that has been excited about having thickened liquids?  Have you ever had a patient comment on the amazing taste of thickened liquids?

What if you are the person responsible for the Modified Barium Swallow Study (MBSS) or Flexible Endoscopic Evaluation of Swallowing (FEES)?  Do you know how to complete the test or interpret the test.  If the answer is no, then you’ve just wasted, money, time and effort.  Accurate completion and reporting of either of these assessments is vital in diagnosing, referring or providing treatment for dysphagia.

Reason Three

Just like you can’t assess and diagnose dysphagia, how can you possibly treat dysphagia when you don’t understand it.

I mean sure, you can throw a list of exercises at a patient, you can modify the diet, but what are you doing for the patient?   What are you actually accomplishing with this patient?

This patient is relying on you to be the expert, to be honest with them and to help them with an issue that is a major roadblock in their recovery.

What can you do?

Don’t turn to social media the night before an evaluation or treatment session knowing nothing about the disease process, the assessment or the treatment protocols.

If you are interested in dysphagia but don’t feel comfortable or confident in dysphagia, find a mentor, read journal articles, shadow, read textbooks.  Learn everything you possibly can about dysphagia.

Be honest with your patient.  I am terrible with fluency.  If I have a referral for a patient with dysfluency, I will more than likely refer them out to an SLP with more experience.  It’s the right thing to do.

Hold paramount your patient’s best interest and never, ever “fake it till you make it.”

  • Tanner, D. C. (2010). Lessons from nursing home dysphagia malpractice litigation. Journal of gerontological nursing36(3), 41-46.
  • American Speech-Language-Hearing Association. (2004). Knowledge and skills needed by speech-language pathologists performing videofluoroscopic swallowing studies.
  • American Speech-Language-Hearing Association. (2002). Knowledge and skills needed by speech-language pathologists providing services to individuals with swallowing and/or feeding disorders.
  • Boaden, E., Davies, S., Storey, L., & Watkins, C. (2006). Inter professional dysphagia framework. University of Central Lancashire, Preston.
  • McAllister, L., & Rose, M. (2000). Speech-language pathology students: Learning clinical reasoning. Clinical reasoning in the health professions, 205-213.
  • Kamal, R. M., Ward, E., & Cornwell, P. (2012). Dysphagia training for speech-language pathologists: Implications for clinical practice. International journal of speech-language pathology14(6), 569-576.
  • ASHA Code of Ethics www.asha.org
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Be the Change

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Let’s face it, we’re not all leaders. Some of us are happy going to our jobs and just done at the end of the shift. Many of us tend to get on social media and complain about issues that we feel are out of our control.

The problem is that just voicing our concerns on social media does not solve the problems. We have to look beyond ASHA and our boss to make these changes.  Now don’t get me wrong, ASHA, management, your state association can be a great start.

You might be asking what are some of these gripes and complaints. Productivity is the big one. We are often asked to work billable time for the majority of our day not allowing us any break for consultation or paperwork that is required of us.  How many of us go in to work,  clock out to maintain our productivity while completing paperwork, making phone calls or some of the necessary but not billable time possible while maintaining 90% productivity or more.   Maybe the reason the productivity expectations exist and the reason that it keeps getting higher is because people are actually meeting these standards. When we give 100% the next expectation will be 110%.

So maybe we can sit and stew about the fact that I’m working on my own time or maybe I can join my state association or ASHA and help bring about change to that productivity.

Another frequent complaint is the lack of instrumental assessment.  Some facilities will not allow instrumental assessment,  however have you presented the cost associated with an pneumonia or with any re-hospitalization compared to the cost of an instrumental assessment?  How can you possibly build an accurate plan of care for your patient when you can’t assess your patient?

When we actually think outside the box that’s when we can get things done.

Continue to educated yourself.  Stop being so complacent with your job.  Stop using non-evidenced based practice and the same oral motor exercises that have been used for 25 years.  Keep up with new practices.  Be a champion and advocate for yourself and for the profession you hopefully love.

When you start standing up for yourself and demonstrating efficiency and competence in your job is when we can show other medical professionals the value in the Speech Language Pathologist in the area of dysphagia.

Stop just posting to gripe on social media and make a change!!