Editor’s Note: This is an excerpt from a guest blog post that originally appeared on Tactus Therapy. In the post, speech-language pathologist Brenda Arend shares highlights of a typical day working in acute care at Providence St. Peter Hospital in Olympia, Washington.
8:30 a.m.: Assigning patients
The first part of my day is spent opening up patient charts in our EPIC electronic medical record and assigning three SLPs to see patients in our 380-bed hospital. Two or three SLPs cover a caseload that ranges from 15 to 30 patients, although recently we see as many as 42. In addition, we also provide outpatient video fluoroscopic swallow studies (VFSS) three days a week. Today, I am assigned to see seven patients and complete the outpatient VFSS.
9:00 a.m.: Re-evaluation in ICU
My first stop is the intensive care unit (ICU) to see a man who had a heart attack. He aspirated secretions during the cardiac arrest and had to be intubated for 10 days. Another SLP assessed him yesterday and determined he wasn’t ready to starting eating orally, so I’m there to re-assess. The patient pulled out his feeding tube yesterday, so the care team is eager to hear the results of my assessment.
10:00 a.m.: Swallowing assessment
My next patient is a lady who had burr holes placed in her skull to remove a blood clot on her brain (a hematoma). She is awake, alert, has excellent oral control, and shows no signs of swallowing difficulty on my bedside evaluation. She looks great! I order a regular-texture diet, write my chart note and sign off.
10:52 a.m.: Not ready yet
When I go to see my next patient, a man in his mid-30s who’s in for street drug overdose, it’s clear he’s not alert enough for a swallowing evaluation today. I let the nurse know and spend 10 minutes talking to her about the nursing swallow screening we want to re-establish. I love opportunities to provide education to nurses who have an interest in what we do.
11:15 a.m.: Upstairs to oncology
This man has cancer at the base of his tongue, so hospital staff placed a tracheostomy tube in his throat to help him breathe. I’ve been following his case to evaluate his swallowing and make sure he can use a one-way speaking valve on his trach tube. Yesterday I did his VFSS using barium-infused food to see how it moves through his mouth and throat. I teach him the Mendelssohn maneuver, the Masako and some range-of-motion exercises for his jaw. I’ll see him again in a week, after his radiation treatment starts.
12:15 p.m.: Lunch!
…and a meeting. While tucking into our lunch, the acute therapy team meets with the inpatient rehab screener twice a week. We share names of patients we think meet requirements for the rehab program and warn the screener of some who may not. I eat, talk to the other therapists and play Candy Crush for a much-needed mental break.
1:15 p.m.: Back to the medical floors
Or so I think! First radiology calls, notifying me of a new inpatient VFSS order. We schedule it for 2:30 p.m., giving me time to see the patient first so I know what to expect. I call the ordering physician and ask for an additional order to see the patient at bedside prior to the VFSS.
1:30 p.m.: Now, to the medical floors
I’m here to see a patient with dementia. I performed a swallowing assessment yesterday and placed her on the baseline textures she was eating at her care facility (pureed solids and thin fluids). Today I check with nursing, read the chart, glance at the intake record and observe her finishing lunch to find she is tolerating her baseline diet. I sign off.
2:00 p.m.: Bedside assessment
Remember that new VFSS order that came at the end of lunch? I go see the patient at his bedside and find him spitting out frothy secretions. He describes symptoms typical of an esophageal disorder, not oropharyngeal dysphagia. Food feels stuck in the mid-sternal region, he has globus sensation (feeling of food sticking low in the throat) and he had two previous esophageal dilations where the connection between the esophagus and stomach are stretched to allow food to pass more easily. I call the doctor to suggest we cancel the VFSS and get a consultation with the gastroenterologist instead. The physician is grateful for my input and agrees to call for a SLP assessment again if this patient shows oropharyngeal dysphagia after the GI evaluation. I call radiology to cancel the VFSS and write my note.
2:45 p.m.: Stroke treatment
I’m off to the neurology floor to see two patients who had strokes: one with dysphagia and one with aphasia. With the dysphagia patient, I review the VFSS done yesterday, so I can plug swallowing deficits seen during the test into my Dysphagia Therapy app and review strategies to target his particular deficits. I get four different exercises, but today I introduce one: the chin tuck against resistance (CTAR) exercise. I also have him practice using a tongue sweep to clear some mild pocketing of food in his cheek after small bites of crackers.
With the patient with aphasia, we work on saying numbers, days of the week, her husband’s name and completing some basic phrases. She’s doing really well! This is exciting because yesterday she could not get out anything more than “yes” and “oh, dear.”
4:00 p.m.: Palliative care
A new order appears on my screen and I’m through today’s list, so I pick up this new patient. A quick review of the chart tells me he is admitted with end-stage chronic obstructive pulmonary disease and has orders for full comfort care (meaning no invasive treatments), but also nothing by mouth. It’s time to take off my “rehab hat” and put on the “comfort care” hat. I enjoy the focus on quality of life when dealing with end-of-life care.
Fortunately, the patient’s daughter is in the room and expresses that she wants him to eat and drink a little. After doing a brief bedside swallow evaluation, I explain the terms “comfort feeding” (just for pleasure, not nutrition) and “aspiration” (food or liquid entering the lungs). Then we talk for a while to figure out the right balance of risk and benefit for her dad. Basically, we want to find the least unsafe diet for him that still satisfies his desire to eat. We land on a pureed diet and sips of thin liquid, allowing him to have a few bites when he is alert enough to swallow. He’s awake enough to agree and thanks me for the spoonfuls of ice cream I gave him earlier.
The next day I found out he passed away in the night, so those ice cream bites were the last food he ever ate. This makes me sad, but also grateful I could help.
5:00 p.m.: Clock out
Time to go home to my family. It was a day of great variety in patients and disorders. Each patient presented complex medical issues I carefully considered in my work with them. This complexity and variety makes work in the acute setting a challenge, but also keeps it interesting!
Brenda Arend, MA, CCC-SLP, has nearly 30 years of experience working in a wide variety of settings with children and adults. She works in acute care at Providence St. Peter Hospital in Olympia, Washington, and serves on the hospital ethics board. Follow her on Twitter at @BrendaArend or email email@example.com.