Dishing on Dysphagia from #ASHA14

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I digested my ASHA 2014 dysphagia notes from 15 hours of courses into these five themes. I appreciate both the clarity from our physical therapy partner in item #1, as well as the tension and uncertainty underlining issues in #2-5 below. Here are the highlights:

1.  Inactivity is worse than smoking, obesity, and alcohol combined per the physical therapist, Mark Richards, at Evidence-Based, Optimal Strength Exercise Parameters: Practice Considerations for Speech Therapists.

SLPs need to review exercise physiology and advocate for effective strength training:

  • Endurance exercise with many repetitions of low intensity at a constant load is NOT effective.
  • Need progression of resistance with the load increasing, otherwise it is maintenance only.
  • Quality strength training of even one set done to fatigue is better than an arbitrary 3 sets of 10.
  • Use the BORG Scale – Rate of Perceived Exertion. The patient should feel the effort is “fairly light” to “somewhat hard” for a moderate level of exercise OR “somewhat hard” to “hard” at the high level.
  • Increased muscle fiber mass and the motor neuron span of control.
  • Increased muscle force strength also increases synchronization and timing for a complex coordinated task like swallowing.

2. A thorough Clinical Swallowing Evaluation (CSE) is valuable, necessary, and should be done prior to instrumental examinations (per James Coyle at Bedside Swallow Examinations: What They Can Do & What They Can’t). Debra Suiter and Laura Sterling were co-presenters and reviewed what a CSE cannot do.

Additionally, Steven Leder, Debra Suiter and Heather Warner (at Simultaneous Clinical & Instrumental Swallow Evaluations: Findings & Consequences) reminded that the CSE should never diagnose pharyngeal dysphagia. Leder stressed the importance of the instrumental exam. For instance, CSE CANNOT evaluate:

  • Bolus flow characteristics
  • Pharyngeal/laryngeal anatomy
  • Hyolaryngeal excursion
  • Pharyngeal delay
  • Pre-swallow spillage
  • Post-swallow residue
  • Swallow physiology. Therefore, we cannot make therapy recommendations based on a CSE (i.e., Masako, Shaker, double swallow, etc.).
  • The following are NOT supported in research as predictors/signs of aspiration: absent gag, changes in oxygen saturation, wet voice, watering eyes, sneezing, and nasal drainage. Even the parameter of a cough can give you a false positive/false negative.

But here’s what the CSE CAN do:

  • Start the patient-clinician relationship. Paula Leslie advises to “shut up and listen,” and sense the feeling in the room.
  • Identify patients who may have dysphagia, may be at risk for aspiration, and may be at risk for pneumonia (i.e., Langmore’s research and oral hygiene research). We know from Leder & Suiter’s research (see references below) that patients who are not oriented, cannot follow 1-step commands, and who have decreased lingual ROM are at increased risk for aspiration. Their research also tells us that if a patient cannot continuously drink 3 ounces of water, he is at an increased risk for aspiration. “Aspiration is volume dependent,” per Leder & Suiter’s research. A patient will not silently aspirate if they are able to complete the full 3 ounces without distress or stopping. However, Stevie Marvin and Amy Baillies (at High-Risk ICU Patients: Managing their Dysphagia Care) showed a FEES exam of an ICU patient who easily consumed the 90 cc of fluid, but he had significant silent aspiration. Marvin & Baillies stressed taking in the big picture of dysphagia risk factors with ICU patients.
  • Develop a hypothesis. Narrow down possible problems. Make appropriate referrals. Let’s not waste time and money doing an oropharyngeal instrumental exam if it is clearly an esophageal issue (of course, keep in mind these frequently co-occur).
  • Share your hypothesis with the radiologist at the MBSS to ensure a thorough instrumental exam, including deploying interventions.
  • Train interventions that can be tested in the instrumental exam.
  • Indicate if instrumental testing is appropriate or not. Is the patient ready for further testing? Will it change anything? Which instrumental exam will best answer the questions? If the goal is palliation, further testing may be academic. Then the CSE’s purpose is to “help the patient aspirate more safely,” per Coyle.
  • Observe lip seal and mastication. We need to realize that we are making an inferences about bolus manipulation and control once the mouth is closed.
  • Observe coordination of respiration and swallowing. Palpating the swallow may not reliably evaluate delay or the extent of hyolaryngeal excursion, but we can note exhale versus inhale after the swallow. If the respiratory rate is >30, the patient may inhale after the swallow, placing him at a higher aspiration risk (per Coyle at What’s Wrong With My Patient?).

The bottom-line is that we need to know why we are doing the CSE and what we expect to get out of it.

3. “Understanding the patient’s disease process is one of the best tools a clinician can have,” reminded James Coyle at What’s Wrong with my Patient? 2014 Update: Pulmonary, Cardiovascular, & Digestive Systems & Conditions Affecting Swallowing. For example, if we do not perform a thorough chart review as part of our CSE, we may think the patient’s pneumonia is a dysphagia-related aspiration pneumonia when it is really a hematogenous pneumonia due to the patient’s sepsis (bacteremia).

 4.“Not everything that can be counted counts. Not everything that counts can be counted.” (William Bruce Cameron, 1963). John Rosenbek and Paula Leslie reminded us of this quote at their session: Ethics & Evidence in Practice. Leslie stated that Evidence-Based Practice (EBP) is one of the most misunderstood issues, forgetting that research is just one aspect out of three. Leslie worded EBP as: an informed clinician checks her knowledge against best available evidence and against informed patient preferences. Rosenbek warned against the “tyranny of the RCT.” In “clean” RCT studies, he asked if we tend to have difficulty finding our patients. For example, Leder noted (at Simultaneous Clinical & Instrumental Swallow Evaluations: Findings & Consequences) how his research on the 3 ounce water swallow excluded patients with tracheostomy, head and neck cancer, and dementia.We should feel a tension between data and belief, per Rosenbek.

Another example of challenges in EBP was from Catriona Steele’s lecture on Diet Texture Terminology. She noted how the Protocol 201 (which is often cited as a reason to not put patients on honey thick liquid) actually used 3000 cp for honey thick as opposed to 1750 cp. This means the research was really comparing nectar thick to pudding thick. “No clear agreed upon taxonomy causes a clear risk to our patients,” per Steele.

 5. “Safe and successful mealtimes are so much more than safe and successful swallowing,” per Samantha Shune at Eating is Not Just Swallowing: Redefining the “Swallowing” Process in the Elderly. This is the perfect example of how the CSE is much more than a screen of swallowing. The act of eating has an anticipatory phase. Shune showed that healthy elderly need more pre-oral time, using all proprioceptive and sensory feedback to prime the motor system. We can ensure that caregivers maximize the mealtime environment to ensure the patients have this compensatory advantage.

 

Bringing it home

So here’s what all this means to me and what I am taking home: Our clinical swallow evaluation is not a screen. We all agree on the limitations of the CSE. However, physicians perform clinical bedside examinations on patients and bill accordingly. They then order instrumental examinations to test their differential diagnoses. We do the same, testing our hypotheses. Per my verbal communication with Steven Leder, he does bill for an evaluation when he performs the Yale Swallow Protocol. However, he also indicated that a nurse could perform this “screening” protocol. We cannot bill for screens. What we do bedside is at a much higher cognitive level of reasoning and critical thinking than just a screen. As Rosenbek said at Ethics & Evidence in Practice: “All of this is why we have frontal lobes.”

We heard our colleagues at the sessions lament that they do not have quick access to instrumental examinations, if at all. What can we do? Some ideas for starters:

  • Document well, stating your hypotheses, as well as the limitations of a bedside CSE.
  • Find Mobile FEES/FEESST and MBS services.
  • Push for adequate staffing and equipment to be able to perform necessary instrumental exams on inpatients.
  • Push for adequate time to review the MBS studies frame-by-frame to “make darn sure of what we see…our recommendations are depending on it,” per Martin Brodsky at Paying it Forward: Training Future Experts in Swallowing Diagnostics. For example, one cannot gather adequate information in real time on 17 components of a MBSImP.
  • Stay open to changes in the field.
  • Maintain positive dialogues.
  • Teach students to expect/embrace uncertainty and realize that there are differing opinions.
  • Thank our trail blazing researchers who are pushing us to question our long-held beliefs!

Speaking of trail blazing, see you next year at ASHA 2015 in Denver, Colorado!

 

Karen Sheffler, MS, CCC-SLP, BCS-S, graduated from the University of Wisconsin-Madison in 1995. Karen has enjoyed medical speech pathology for 20 years. She is a member of the Dysphagia Research Society and the Special Interest Group 13: Swallowing and Swallowing Disorders. Karen obtained her BCS-S (Board Certified Specialist in Swallowing and Swallowing Disorders) in August of 2012. She has lectured on dysphagia in the hospital setting, to dental students at the Tufts University Dental School, and on Lateral Medullary Syndrome at the 2011 ASHA convention. Special interests include neurological conditions, geriatrics, oral hygiene, and patient safety/risk management. Karen continues to work in acute care and is a consultant for SEC Medical. She started the website and blog www.SwallowStudy.com in May 2014. She has blog posts on ASHAsphere and www.DysphagiaCafe.com. You can also follower her on Twitter, Facebook or on PinterestSheffler was one of four invited bloggers for ASHA’s 2014 Convention in Orlando.

References:

Leder SB, Suiter DM. The Yale Swallow Protocol: An Evidenced-Based Approach to Decision Making. Springer, NY, 2014.

Suiter DB, Leder SB. Clinical utility of the 3 ounce water swallow test. Dysphagia. 23:244-250, 2008.

Leder SB, Suiter DM, Green BG. Silent aspiration risk is volume dependent. Dysphagia 26:304-309, 2011.

Cooking up the Perfect ASHA 2014

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What’s the perfect recipe for ASHA 2014? Blend together science, learning and practice. Add a pinch of party and a heaping of gratitude. Watch it grow for generations.

Like many SLP swallowologists, I’m a foodie. Expand that: I’m a bilingual (Spanish-speaking)-Canadian-American-Salsa-dancing-foodie-mama-dysphagia nut, ready for a stimulating convention getaway in Florida. Good thing ASHA has cooked-up a feast for the body and mind.

Coming from Boston, I’ll feel right at home Wednesday night at Minus5º Ice Bar for the ASHA-PAC Party. Drinking a cocktail in a glass made out of ice may make you swallow faster! Watch out! The icy architecture will cool us down as we discuss the latest political action on Capitol Hill.

On Thursday, ASHA promises “hot, hot, hot” at the The ASHFoundation Latin Party at Cuba Libre Restaurant & Rum Bar. After we swallow liquids, we can test solids from the award-winning chef Guillermo Pernot. Salsa lessons anyone?

But of course we won’t just be there to party– relaxing and dancing will help us learn better.

 

Gratitude for opportunities in Science & Learning

I love seeing my heroes at conventions. This year we are deeply saddened to have lost our pioneer in dysphagia, Jerilyn Logemann.

As we remember Logemann, we also need to remember to thank all our mentors. Take time to reflect on how much they have influenced you and your career. Who would I be today without teachers like Jay Rosenbeck, Joanne Robbins, and James Coyle during my master’s studies years ago? Thank you!

And not just mentors who you know directly, but those who are influencing the profession, too. Thank you Catriona Steele, University of Toronto, for pushing us to go global. She suggests an international consensus for diet texture terminology. How many names do we have for that safe-ish dysphagia diet between puree and regular? Here are a few: mechanical soft, ground, moist ground, chopped, mechanically altered…

Thank you Tessa Goldsmith, Partners MGH, for the very important exploration of Human Papilloma Virus (HPV). SLPs are public health advocates. Michael Douglas was misdiagnosed three times, delaying his treatment by too many months. He said it started with a sore throat and sore gums behind his last molar. As rates of laryngeal cancer from smoking decline, HPV has emerged as the most common cause of oropharyngeal cancer. However, there are many differences between HPV-positive and HPV-negative cancers. Additionally, don’t miss a chance to see Katherine Hutcheson, of MD Anderson, who gave a fabulous series at the ASHA Healthcare & Business Institute this past April. Jeri Logemann co-authored a two-part series on Long-Term Dysphagia After Head & Neck Cancer. Thank you to her team for carrying the torch.

I appreciate how Dr James Coyle is like Socrates, probing with critical questions to seek the truth. His courses ask: Which side is up?; What’s wrong with my patient?; What are we doing and why?; and what can bedside swallowing examinations do and what can’t they do? Every SLP practicing in dysphagia has to take at least one of his courses. We will learn a lot of science that directly relates to our practice, while having fun! I try to capture his humor in my blogs.

Another thank you to the twilight session on Thursday, called “Eating is Not Just Swallowing.” Samantha Shune, University of Iowa, integrates “components of the broader mealtime process with our definition of swallowing.” I typically introduce my bedside swallowing evaluations with: “Your doctor wants me to evaluate your eating and swallowing.” However, I was once told at an old job to not say “eating,” because it was deemed unrelated to swallowing and swallowing impairment. I appreciate this session’s holistic perspective.

 

Generations of Discovery

ASHA conventions inspire growth. I have discovered that you can recreate your career at any age. After performing Modified Barium Swallow Studies for 15 years, I am beginning again in an extensive FEES training program.

This past April at the ASHA Healthcare & Business Institute, a group of us were sharing our dreams and goals for our careers. I realized that I love to constantly learn, synthesize, and share with others. One year ago, I never would have believed that I would start a dysphagia resource website and become an SLP blogger.

As us older generations teach the younger generations, we also need to thank the younger SLPs for inspiring us to keep it fresh. For me that meant finally embracing technology. It is technology that is helping ASHA members network and reach all corners of the globe.

Thank you, ASHA, for this feast!

 

Karen Sheffler, MS, CCC-SLP, BCS-S, graduated from the University of Wisconsin-Madison in 1995. Karen has enjoyed medical speech pathology for 20 years. She is a member of the Dysphagia Research Society and the Special Interest Group 13: Swallowing and Swallowing Disorders. Karen obtained her BCS-S (Board Certified Specialist in Swallowing and Swallowing Disorders) in August of 2012. She has lectured on dysphagia in the hospital setting, to dental students at the Tufts University Dental School, and on Lateral Medullary Syndrome at the 2011 ASHA convention. Special interests include neurological conditions, geriatrics, oral hygiene, and patient safety/risk management. Karen continues to work in acute care and is a consultant for SEC Medical. She started the website and blog www.SwallowStudy.com in May 2014. She has blog posts on ASHAsphere and www.DysphagiaCafe.com. Sheffler is one of four invited bloggers for ASHA’s 2014 Convention in Orlando.

10 Trillion Microorganisms versus Your Toothbrush

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“The mouth is dirty,” Dr Kenneth Shay stated frankly; AND, it is “the biggest hole in your body!”

Warning: You may want to finish eating, brush your teeth, floss, use mouthwash, and then come back…

OR

If it is early morning, and you haven’t brushed your teeth yet: then scrape the gunk off your teeth with your fingernail. You may have found 10 billion microorganisms in that cubic millimeter.

There are 1 trillion to 10 trillion microorganisms in your mouth. Simply brushing your teeth can get rid of that nasty bacteria film in your mouth. It can also prevent “some of that schmutz” from getting into your lungs. If you are having trace aspiration (saliva, food, and/or liquids getting into your lungs), try to make what gets into your lungs less nasty. You can prevent pneumonia. Pneumonia due to poor oral care is a major avoidable infection, per Shay.

Ross & Crumpler (2006) noted that despite strong evidence in the literature on the role of brushing the teeth in preventing pneumonia, medical staff continue to view oral care as a comfort measure and only use foam swabs.

“Toothette sponges are wimpy,” stressed Shay. They don’t get the gunk (plaque) off the teeth. Plaque is sticky. If not removed, it hardens into tarter (also known as calculus). Then a visit to the dentist is needed to get it off (debridement).

Why is the mouth forgotten in healthcare? We help the dependent elder go to the bathroom many times a day. So why don’t we help brush his teeth?I’ve heard some nurses say they are squeamish about the mouth! It makes them gag! Well, we should be gagging over the costs of neglecting the mouth.

This simple prevention technique of brushing costs pennies a day against the cost of a pneumonia. Based on CDC numbers from 2011, there were 157,500 Hospital Acquired Pneumonia infections that year. CDC states the average extra cost of that hospital acquired infection is $22,875. This equals over 3 billion dollars!

Why are we not protecting this wide open gateway to the body? Imagine your gingival space between the tooth and gum as a huge parking lot. Germs love these 1-3 millimeter deep parking spaces. If germs park in the gingival space for more than 24 hours, they become calcified into plaques. Bacterial loves to stick to plaque. Only brushing removes it. No brushing leads to a build-up of plaque in the gingival space and inflammation (gingivitis).

It only takes 48 hours of hospitalization in a critically ill patient to change this bacteria from the usual gram-positive streptococci to gram-negative microorganisms (the nasty pathogenic bacteria that cause pneumonia).
Maybe we don’t brush our patients teeth because the gums bleed? Blood is okay, per Shay, even if you are on a blood thinner. Shay stated that bleeding is a sign that you need to brush more. It is due to the inflammation, and regular brushing will prevent bleeding. Shay warned that bleeding is only risky if the patient has a blood disorder or disease that causes excessive bleeding.

Most cases of gingivitis do not progress to the more serious periodontitis, but…Immune-compromising events can cause an autoimmune response that can lead to periodontitis, per Shay. Examples of immunocompromising events are not only hospitalization and critical illness; they could also be the following:

• life stressors
• flu
• depression, and
• pregnancy

Periodontitis is inflammation caused by bacteria that affects the attachment between the tooth and the bone. It is an irreversible destruction of the supporting tissues (i.e., the periodontal ligament to alveolar bone). Then bone-absorbing cells eat away at the bone. The bone will not be regenerated. Additionally, with the gums receding, “there is more surface area to collect gunk,” said Shay. The periodontal pocket that is formed creates a larger “parking garage” of 6-8 millimeters deep. Lots of gram-negative anaerobic bacteria can park there! Pathogenic microorganisms. “These are the same things that cause aspiration pneumonia,” stated Shay.

See the full blog post at www.swallowstudy.com.

Karen Sheffler, MS, CCC-SLP, BCS-S, graduated from the University of Wisconsin-Madison in 1995 with her master’s degree. There, she was under the influence of the great mentors in the field of dysphagia like Dr. John (Jay) Rosenbek, Dr. JoAnne Robbins, and Dr. James L. Coyle. Once the “dysphagia bug” bit, she has never looked back. Karen has always enjoyed medical speech pathology, working in skilled nursing facilities and rehabilitation centers in the 1990s, and now in acute care in the Boston area for more than 14 years. She has trained graduate student clinicians during their acute care internships for more than 10 years. Special interests include neurological conditions, esophageal dysphagia, geriatrics, end-of-life considerations, and patient safety/risk management. She has lectured on various topics in dysphagia in the hospital setting, to dental students at the Tufts University Dental School, and on Lateral Medullary Syndrome at the 2011 ASHA convention. She is a member of the Dysphagia Research Society and the Special Interest Group 13: Swallowing and Swallowing Disorders. Karen obtained her BCS-S (Board Certified Specialist in Swallowing and Swallowing Disorders) in August of 2012. You can follow her blog, www.swallowstudy.com.

7 Clues in the Medical Record to Discover Dysphagia

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Medical speech pathology has its uncertainties.This may cause the speech-language pathologist to be very conservative, possibly over-treating or overcompensating, per James Coyle, PhD, CCC-SLP, BCS-S at his talk on April 11, 2014, at the ASHA Healthcare & Business Institute.

“When the cause of dysphagia is not obvious: Sorting through treasure and surprises in the medical record.”

Coyle advised clinicians to value the medical record just as much as our direct examination of the patient. The “medical record is a messy place,” per Coyle. It is our job to dig for clues to distinguish which came first: the illness or the dysphagia. Some conditions can mimic dysphagia-related aspiration pneumonia. Some community acquired infections can create weakness and delirium, which then cause an acute dysphagia.

Let’s start with a story: An active-independent elderly female develops a urinary tract infection (UTI). She feels sleepy and stops eating/drinking regularly. This worsens the UTI and causes dehydration. She gets to the hospital four days after the onset of symptoms. Dehydration causes electrolyte imbalances, leading to delirium. Delirium + infection = more lethargy and a global cognitive decline. Being out of her usual environment causes more confusion and agitation. Antipsychotic medications are used to control the acute agitation. The patient becomes septic, as the infectious process spreads. Her urosepsis spreads to a pneumonia. The SLP notes a high aspiration risk, as the patient looks severely impaired. Unfortunately, without a thorough medical record review, the patient is labeled with dysphagia-related aspiration pneumonia. She stays on thickened liquids and pureed foods until hospital discharge. Will the patient fall through the cracks and never eat regular food again? Will the “Big-A-word” (ASPIRATION) follow her the rest of her life? Or will an SLP re-evaluate her in two weeks and discover that her dysphagia has disappeared?

I have summarized Coyle’s talk into these seven clues (more details and references in my full post).

1)    Is it pneumonia?

  • New infiltrate on CXR. Dependent lobes? Not necessarily only the lower lobes if the patient is bedridden or aspirating while laying down on the couch.
  • Leukocytosis (WBC count of >11.5-12.0). Warning: immune-compromised patients cannot make white blood cells.
  • Fever (>38 Celsius for >24 hours)

 

2)    What type of pneumonia is it?

  • Ventilator Acquired Pneumonia (VAP): May be widespread infiltrates. Strong correlation with oral pathogens.
  • Dysphagia-Related Aspiration Pneumonia (DAP): A recurrent pneumonia may be one big infection from ongoing aspiration. Perform a swallow study to determine if dysphagia is present and why. This is so important. If we label them with DAP, that patient’s past medical history will forever say “Aspiration Pneumonia.” Then medical personnel may be overly conservative in the future.
  • Non-Dysphagia-Related Aspiration Pneumonia (NDAP) and/or Aspiration Pneumonitis: if no dysphagia present before infection, check history for chemical irritants, allergens, reflux, a vomiting event, or use of acid-suppression therapy (i.e., Proton-Pump Inhibitors).
  • Hospital Acquired Pneumonia (HAP) or Health Care Acquired Pneumonia (HCAP): pathogens from the institution getting into the lung. Aspiration?
  • Community Acquired Pneumonia (CAP): may be diffuse infiltrates and not in dependent lobes.

 

3)    What was the patient’s baseline? “You got to have dysphagia to have dysphagia,” joked Coyle. “But seriously,” he added, “I can’t underscore this enough.” Dysphagia-Related Aspiration Pneumonia (DAP) requires the finding of difficulty swallowing prior to getting sick. Be a detective.

 

4)    Is there a systemic spread of infection (e.g., septicemia or sepsis)?

  • Sources: The lung is not the sole source for the primary infection. Wound, oral cavity, urinary tract?
  • Problem: The patient may not develop sudden signs, but it can unfold rapidly. Coyle urged SLPs to be careful when predicting goals for the future, as “sick people look pretty darn sick.” Good communication is needed at discharge to ensure re-evaluations.
  • Ask the medical team questions: Is this a short-term reversible problem? Could this be an acute dysphagia due to the illness?

 

5)    Was there a surgical procedure that could have caused the dysphagia? For examples: cardiothoracic surgery, lung transplant, lung resection, esophagectomy, head/neck cancer resection. Coyle recommended Atkins, et al (2007). See references on my full post.

 

6)    Was there a medical procedure that could have caused the dysphagia or an aspiration? For examples: feeding tubes, prolonged intubation, traumatic intubation, peri-operative aspiration event, chemotherapy/radiation.

 

7)    Are there medications that could be causing the aspiration, dysphagia, or pneumonia?

  • Polypharmacy increases a patient’s pneumonia risk.
  • Coyle recommended reading Knol, et al (2008). This was a case controlled study of elderly patients with age-matched controls. Patients who received antipsychotics where 60% more likely to have pneumonia.
  • Read more possibilities on my full post.

 

Our answers to these questions have a great impact on all we do: from our initial examination and instrumental evaluations through our discharge plan and beyond. SLPs do not diagnose pneumonia, but our communication with the medical team is an extremely valuable contribution to their differential diagnosis.

 

Karen Sheffler, MS, CCC-SLP, BCS-S, graduated from the University of Wisconsin-Madison in 1995 with her master’s degree. There, she was under the influence of the great mentors in the field of dysphagia like Dr. John (Jay) Rosenbek, Dr. JoAnne Robbins, and Dr. James L. Coyle. Once the “dysphagia bug” bit, she has never looked back. Karen has always enjoyed medical speech pathology, working in skilled nursing facilities and rehabilitation centers in the 1990s, and now in acute care in the Boston area for more than 14 years. She has trained graduate student clinicians during their acute care internships for more than 10 years. Special interests include neurological conditions, esophageal dysphagia, geriatrics, end-of-life considerations, and patient safety/risk management. She has lectured on various topics in dysphagia in the hospital setting, to dental students at the Tufts University Dental School, and on Lateral Medullary Syndrome at the 2011 ASHA convention. She is a member of the Dysphagia Research Society and the Special Interest Group 13: Swallowing and Swallowing Disorders. Karen obtained her BCS-S (Board Certified Specialist in Swallowing and Swallowing Disorders) in August of 2012. You can follow her blog, www.swallowstudy.com.