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How do speech-language pathologists save lives? How can we more fully utilize them in the ICU? How can PT, OT, AND SLP help, halt, or reverse pulmonary disease processes during acute and critical illness? Let’s discuss how they prevent harm and restore humanity in the ICU.

Episode Transcription

Kali Dayton 0:28
Okay, way back in episode 30, speech language pathologist, Lydia shared with us a lot of the science behind a speech language pathology. As I’ve had the honor to work with clinicians and teams throughout the world, I am realizing the variation and roles and participation SLPs are allowed to have in the ICU, it is time to wake up and open the doors for these life saving experts to come in and work their magic. I am thrilled to have Suzanne Ball teach us so much about speech language pathology in the ICU. Suzanne, welcome to the podcast. Thank you for coming on. Will you just give us a little introduction to yourself?

Suzanne Ball 1:11
Sure. So I’m Suzanne ball. I’m an SLP. I have primarily worked in hospitals. So far, I’ve worked at four different trauma centers. And now I’m actually trying to transition out to my own private practice, where while I’ll be doing endoscopy, and that’s basically just a different type of swallow study than what you’re probably used to in the hospital. And that allows us to do this follow city right at bedside in the nursing home. But like I said, most of my experience has been in the hospital, I’ve worked at four different trauma centers ranging between level one and level two.

Kali Dayton 1:48
And so as an SLP, or speech language pathologist in the ICU, how would you see your role as an SLP? In the ICU? And what kind of barriers in our culture impede your ability to apply your expertise to patient care?

Suzanne Ball 2:07
So I love this question. Because I think a lot of times people don’t really know what SLPs do, and we are definitely under utilized. Now, the scope of practice for speech language pathologist is incredibly broad. We work from birth to death, and all different kinds of settings. But primarily in the ICU, we’re really targeting three things. So we’ll work with patients with dysphasia, which is just a fancy word for swallowing problems.

We want to work on communication methods, and specifically, for example, our patients that are not able to communicate with us. So nonverbal communication, and also delirium management, which has to do with cognition. So there’s three things that we can really target. Now, just a heads up, I’m probably going to talk about some of the things that you’re going to make you wonder, you know, why isn’t SLP talking about this, but as an SLP, because our scope is so broad, and the things that I’m working with on patients, you know, thinking, talking, swallowing, those are all in a shared system.

So SLPs really need to know a little bit about, you know, the respiratory system and the GI system, the brain, how does the medication affect patients? But in no way do I want to report that I’m, you know, an expert in these areas, but SLPs do know a little bit about these things, since we have to use them in our daily work. And, you know, I think sometimes with the sedation in mobility culture, nurses are afraid that their patients, you know, might get agitated, and a lot of times I see it as a nurse wants to protect their patient, they want them to be safe and not have trouble.

So sometimes I’ll see SLP is turned away as in, no, you know, the patient’s just not doing good today, or, you know, their coffee a lot, or their vitals are just really unstable. But from the SLP standpoint, you know, we know how to look at a monitor and see the vitals and we can give more feedback on, you know, your patient that’s agitated, how can we return work on you know, delirium strategies.

And those patients that, you know, are not being mobilized are not working the muscles that you see, you know, moving their arms and their legs, but they’re also not working, they’re swallowing and they’re breathing muscles. So even if we’re not physically doing something with your patient, we still have input that we can give you and we want to help you. So basically, let us help you by asking questions and inviting us in.

Kali Dayton 4:50
Oh, I love it. Suzanne, that’s so many good points, and I’m just reflecting on my practice in the wake and walk in ICU. I talked with speed Just every day at least once a shift, then I’m gonna give me a report on everyone and we talk about swallow. But we also talk about delirium, cognition, they’re doing mocha scores on people. They’re giving insights into what’s causing their agitation, what else can we do? What are the barriers to communication?

So I think you’re right, I think we just think that you guys are there to give the thumbs up or down whether or not they can swallow. But how much are we missing out? How much better can we do for patients, if we actually let you do your job. And you talk about immobility, and how much that impacts patients, but also your ability to work with them. So how does our sedation and mobility culture impact your role and the problems that you have to address with patients or would like to address.

Suzanne Ball 5:51
So there’s so many directions I can go in, in with this first, I want to talk about, you know, as a therapist, I want to track progress. And I want to be able to demonstrate that what I’m doing is working because if it’s not, I have to change what I’m doing. And, you know, when someone is sedated, or for example, in one of your other episodes, I was hearing of a story where, you know, a nurse was trying to prevent this idea of sitting patient all the time.

But then when she’d come back, she realized that the nurse followed up with that followed behind her was studying the patient more, and it became this fluctuation of you never know what you’re going to be presented with. So the patient can be distrustful towards the medical personnel. And then not only is the presentation that I’m seeing as a therapist, you know, not really consistent.

So how can I truly evaluate somebody, give a plan of care, and then measure outcomes to track progress. So having this inconsistency is a huge barrier for therapists to also just justify what we’re doing. And then if what I’m doing with a patient isn’t showing consistent results, that also breeds distrust with the medical team, the nurses aren’t going to believe in what I’m doing. And the physicians aren’t going to believe in what I’m doing. Because the patient’s presentation is changing. So frequently,

Kali Dayton 7:25
Example of when that happens.

Suzanne Ball 7:29
Sure. So for example, I have gone to see a patient, and they’re nice, they’re awake, you know, maybe they’re a little disoriented, but we go in and we do some oral care, we get them sitting up, talk them a little bit, then we can give them some things to eat and drink. And then I go in the next day, and they’ve been given, you know, fentanyl, or Ativan, and they are just wiped out.

And so now I have to go address this problem with the physician and say, “hey, they’re not going to meet their nutritional needs or their hydration, not to mention you’re giving them oral medication, you know, is this patient really going to meet their medical needs, as well as their nutritional hydration needs? If they’re not able to consume the diet that I recommended?” And again, that reflects poorly on me, not the medical management? Because I recommended something that looked like it was appropriate yesterday. And now it’s not appropriate today.

Kali Dayton 8:30
Wow. Yeah. So on the podcast, I dress sedation and immobility for patients on mechanical ventilation. Because that’s when we have continuous sedation going right. And then, from my experience, you know, patients are not sedated, hardly ever and they are awake and moving on the ventilator, right, this great scenario, and then they get extubated successfully. And then hours later, usually, maybe the next day, they’re having an evaluation with speech, and they’re okay to eat and we’re not giving them any further benzos hardly ever, you know, maybe some like narcotics.

Um, if they’re delirious or not, you know, fluctuating that much. I had not thought about what it’s like for you, when you come in, and a patient’s had, I don’t even like to say the word out of hand. I, it still shocks me that we’re given IV Ativan so casually, but that does put you in a hard position because that’s not the same patient you saw the day before, even a few hours prior.

And I see, just on the note of Ativan, that’s I’ve been doing a medical review, I saw one patient that I was reviewing, they were getting out of it almost around the clock. And so, like how PT and OT were getting frustrated and namens putting their notes. nurse gave the clearance for therapy today. But when I went in, the patient had just had Ativan and can’t even hold their heads up. Yep. And so I could see from those therapists or frustration, I had not thought of it from speech therapy.

Suzanne Ball 10:03
So I mean, it impacts not only swallowing and breathing, but I mean, also their cognitive communication. I mean, even the patients on the ventilator, if they’re able to be awake, we can communicate with them. And they can communicate with us, as you seen. But again, the sedation is going to prohibit them from having their own autonomy in their care and communicating with us. And we’re not going to be able to, you know, see patient changes in meditation if they’re being sedated.

Kali Dayton 10:34
Yeah, I mean, there’s so many problems there. How do you even do a real neural exam or evaluate their cognition when they’re sedated, right, and even for swallowing. So as I mentioned, a lot of these patients from awake and walk in ICU, they’re eating pretty quickly after extubation. It fluctuates right by the patient. But what do you see, as far as if a patient’s awake? I don’t know what the mobility is like your facility, but a patient’s awake, and they’re communicating on the ventilator? How do you see that impact their ability to resume oral intake, after extubation.

Suzanne Ball 11:08
So research has shown that patients can experience something called post extubation, or post post extubation dysphasia, which basically just means that since they’ve had that tube, and their muscles have begun to atrophy, they could have had tissue irritation, there’s just a multitude of things that can go wrong, even if someone experiences like a traumatic intubation, that can impact their swallowing and their breathing.

So something that’s unique about swallowing is that it occurs in a shared space. So we can never look at swallowing and by itself, but we also have to think about the impact of breathing. And when we have patients that, you know, are more at risk for developing pneumonia, because of their poor mobility, you know, that’s going to have a long term impact on their swallowing as well, because they have to coordinate their breathing with their swallowing.

So everything that happens in the ICU, can impact someone’s ability to eat and drink, whether it’s sedation, the pharmaceuticals, their positioning, you know, their have to or their oxygenation method. So there’s so many factors to think about, it’s not just is the patient awake and alert, can they eat and drink. So I’ve been in a couple of different hospitals now, like I said, I’ve been in for, and they all operate very differently.

Some, the SLPs are extremely involved, and they’ll get right in there in the ICU, they do a bedside assessment, at they see signs and symptoms, you know, they order an appropriate instrumental evaluation to see what’s going on in there. And then some others I’ve been at, you know, SLPs don’t really have a huge presence in the ICU, which I think is doing the patients a huge disservice. Because swallowing is so integral to people’s, you know, idea of themselves because eating and drinking is such a personal experience, that I can’t imagine how demoralizing it must be to have that taken away from you with some of these patients that are put on non-rural nutrition, when the SLP is not involved.

Kali Dayton 13:31
Yeah, when we talk about humanizing medicine, eating and drinking as part of our humanity. It’s part of our joys in life, I hadn’t really pieced that together, and it blows my mind that ICUs wouldn’t have SOPs that involved. But I’m thinking back to our SOP and she was because the way can walk in ICU as part of a multi hospital system. She was in a meeting with other SLPs from other hospitals and the system.

And she personally works the floor and the ICU. And she kept on referring to work in the ICU and these other SLP said, Why are you in the ICU? Oh, yeah. What do you do? What’s your role? They were so confused. I mean, sedation mobility, deeply impact your role. So she’s in a nice in an ICU where people are extubated, they’re awake on the ventilator, and they there, there’s such an a need for SLPs. But when you just deeply state people, everything after fees, they’re not. They’re really not appropriate for oral intake, and they’re not going to be for a long time.

And I’m thinking about muscle atrophy I think I always thought about the swallowing muscles being atrophied because obviously we’re not swallowing, we’re not talking. We’re not managing oral secretions. But now that I’ve been doing more research, especially on the podcast, talking about muscle atrophy, and how that provokes greater inflammatory response, and the morning inflammation there is in the body, the more of muscles atrophy, and the impact of sedation on muscles.

And now I’m starting to see it as how does that apply to all the muscles used for speech and swallowing and breathing? So even if someone’s on a ventilator for a shorter, shorter amount of time, then maybe someone in the awakened walking ICU, I’m speculating, right. So if someone’s on the ventilator deeply sedated for a week and a half, and a normal ICU, some of them on Twitter for three weeks in the wake can walk in ICU, Brian Carter and episode 15. That was his story. He was eating the next day after being on the ventilator for three weeks. That’s amazing. What would you how would you explain that?

Suzanne Ball 15:41
Well, first, everyone’s body is different. And I mean, to me, this was so evident when I first started doing video fluoroscopy. So that’s basically just a modified barium swallow study. We’re taught in school that, you know, everyone has these anatomical parts, and they’re all supposed to physiologically move and work a certain way. However, we know everyone’s anatomy is a little bit different, and the shapes and sizes and the way that it works.

And in a situation like that, he sounds like he’s a very lucky man. Because, you know, after someone has been intubated, for a period, like three weeks, I would 100% be expecting for them to have some sort of symptoms of dysphasia. Because not only is there the motor mobility aspect, but the sedation aspect, and we know that in swallowing, it’s not just motor, so let’s think about our nerves and how they innervate our muscles. So their role is not just motor, it’s also sensory. And by not using the muscles, they’re being deconditioned, they’re weakened.

And that leads to poor coordination of those swelling muscles. And just listen, this numbers amazing, we have 39 paired muscles that help us swallow. So 39 muscles are not being used as the way they used to. And all those muscles have to coordinate to protect your airway, and to get what you’re eating and drinking down the right path. So it has two jobs. And that’s just the motor aspect. And then when you bring in, for example, like sedation, sedation, in a study that I found, it showed that it compromises the sensory response to aspirated material, so you can have a compromised cough reflex.

And, you know, maybe even a delayed swallow initiation because your sensation has been impacted, as well. So there’s two aspects to this, that sedation and mobility are both hindering, you know, swallowing, and breathing, because they work together. You know, when you’re swallowing, you have a APNIC period, so you’re not breathing. So your body is, is truly working a miracle every time you eat and drink that is able to coordinate all those muscles and protect your airway at the same time. Wow, what

Kali Dayton 18:14
a great explanation. And in a previous episode, I talked about paralytics, as well, the impact that they have on the nerves. And I again, had not applied that to sensory to coordinating muscles for swallowing. And yet you make perfect sense. Thank you. And so your role fluctuates by facility because of their sedation and mobility culture, and probably their interdisciplinary approach as well. Right?

Suzanne Ball 18:46
Correct. Correct. So, I’ve been in a hospital where the SLP, attends rounds, critical care rounds. And I think that’s amazing. And then I’ve been in a hospital where the SLP barely ever gets any consults to go into the ICU. Because just as your SLP friend saw, they don’t understand themselves, even how they can benefit. And I don’t think that this is something that’s really taught in school for SLPs. So a lot of the learning that I did about critical care, trauma was done after school, and I had to spend a lot of my own time and money learning about these things.

And I have had really great mentors. So unfortunately, I think some SLPs might not understand, but I do know something about SLPs is that we love learning and we like to talk so as a nurse or a physician, or anyone that’s in the critical care world. You can draw SLPs into learning about this by asking questions, you know, we all have to start somewhere and learn this

Kali Dayton 19:59
stuff. Yeah, and during the webinars, I’m telling everyone to bring all the disciplines to the table to listen to the webinar. And some people are like, yep, we already invited everyone in some teams are thinking why? There’s, we just, it just changes so much. But that’s a great point, we can invite our SLPs. And then SLPs demand a seat at the table. Yes. So if you’re way in there, you have every right to be in there. You do, right? This is, as we’re transitioning critical care medicine to not just be for that shift. For that moment, we’re looking at the big picture, you are an integral part of humanizing ICU and preserving and restoring humanity into medicine.

Suzanne Ball 20:45
And I love that because, you know, I think when patients are in the ICU, I’m sure everyone that’s there, especially their family, they’re thinking about that moment, you know, survival, either I’m critically ill, or I’ve had some kind of traumatic injury. And we just have to, you know, take the small steps and get through this moment, but as a therapist, not just an SLP.

But you know, PT, OTs, I think we kind of have a more long term, look, because when we’re in assessing, we’re also thinking about discharge disposition. So what’s the prognosis for this patient? What, you know, what were they like, before they came in here? What was their job? What was their education level? Where they a caregiver? How can we get them back there as soon as possible? Not only for their sake, but we also have to think, you know, about caregiver burden burden on society. So rehabbing from the very beginning. In the ICU, can shorten, you know, subacute stays as well, and get them closer to being themselves getting getting them home.

Kali Dayton 21:57
And what a neat role, you could have it educating the ICU community on the big picture as far as peg tubes, feeding tubes, swallow rehabilitation, and the long term pictures, I don’t think, you know, feeding tubes are just so normal. And you know, and MFT is normal and the waking one, can I see you and I think a lot of ICs, it’s normal to just pick everyone. But a speech can come and say, let’s put a halt. Let’s stop them. Look at this. What if we kept them away, kept on moving, I can rehabilitate them in the hospital, there’s so much more likely to be able to leave and not need any of that anymore. Yes, let’s plan together to achieve that goal.

Suzanne Ball 22:39
Absolutely. And I’m so glad you brought up PEGS. This is just such a pervasive issue. And it’s not black and white. Unfortunately, you know, I think I want to stay away from Prescriptivism and go and more towards individual patient care. So say a patient has dysphasia, or their aspirating is not automatically Oh, this patient asked for its they get a peg is never blanket, black and white for patients. Or it shouldn’t be right. Correct, it should not be.

So first, in talking about pegs, I want to strongly underscore the importance of making it a whole team decision. And the patient in the family need to be the primary people here. You know, SLPs have a great role in the ICU, like we’ve talked about in diagnosing dysphasia, identifying the specific impairments and what’s going wrong, and finding alternative ways to help them get their nutrition hydration. But those alternative ways don’t always have to be non oral nutrition. It can be compensatory strategies, or diet modification. And the reason why I say this is because I don’t want anyone to ever think that SLPs have the authority to just say that a patient should be pegged.

Ultimately, you know, it’s a group decision between the physician, the therapist, the family, the nurses. And I think that by making a group decision, we’ll be able to stay further away from fear based decision making. And I think that’s really pervasive right now in the SLP culture, actually. So I think SLPs are afraid that they’re going to be blamed if a patient develops pneumonia. Because it’s actually quite hard to diagnose aspiration pneumonia, you can’t just say, Oh, they have you know, bilateral infiltrates as an independent lung zone, it must be aspiration pneumonia, but oftentimes that will be on the patient’s chart.

And then you know, SLPs are kind of looked at and the finger gets waved at them that we didn’t do something to protect the patient. So I really want to emphasize how this is so medically complex that it should never just lie on the shoulders of the SLP. And in 2002, there was a study that purported that actually nonverbal nutrition such as Pegues, was a way to prevent aspiration malnutrition. But there has been numerous and I mean, so many studies that have contradicted that and say otherwise. So, what I hope SLPs know, and will educate other critical care workers, like nurses and physicians is that pegs and NG tubes, top half tubes do not prevent aspiration.

And they don’t always prevent malnutrition either. So, what I would love to urge people to do is always do instrumental assessments, if the patient is able to, you know, as an SLP, I don’t always understand everything that’s going on medically with a patient. And I’m sure there’s going to be times where a peg is medically necessary. And that is for the physician to decide. However, when it comes to dysphasia, and a patient getting a peg due to that diagnosis, sometimes I think we can be doing a little bit better with that. And what I mean by that, is that placing a peg to prevent aspiration is not necessarily what is going to happen. So we have to step back and look about look at really what is going on here. So as you and I both know, when a patient gets a peg, they can be at risk for infection, aspiration of their reflux, aspiration of their own secretions with other numerous gi problems that I don’t even fully understand. So

Kali Dayton 26:57
Dislodgement…

Suzanne Ball 26:59
Exactly, exactly. I mean, I’ve seen patients that take out their own pegs, because they didn’t want them. And I’m sitting here thinking, why did why did we just think this person go through this. But what’s important to know is that there are other ways to prevent aspiration pneumonia. And it’s not just pegs. So I don’t know how it is in your hospital. Not all hospitals, provide oral care materials to the patient.

I’ve had I found myself going into the you know, the utility area where they keep all the supplies and just dumping materials in one of the MSS buckets and bring into the patient room. And I’m the first one that has done any oral care for these people sometimes. And we know from a study done by Les more, that the development of aspiration pneumonia is not dependent on dysphasia. But it’s dependent on a multitude of factors. So even if a patient asks for AIDS, that doesn’t mean that they’re going to develop pneumonia, it means that they could if they have the perfect storm.

So what I mean by that is, you know, deconditioning through immobility, poor positioning in the bed, poor oral care. And then on top of that, you have the dysphasia resulting in aspiration. So all of these things compound on top of each other, to allow this bacteria to manifest and just fester in the lungs. Now, we do know, for example, that everybody aspirates people with dysphasia can aspirate more larger quantities more often.

And we know that the reason why they’re developing this pneumonia from this event is because they’re carrying that bacteria down from their oral mucosa. So every single day, we have bacteria growing and repopulating in our mouth like you and I, I’m sure before we go on our shift to work that we brush our teeth looking great go into work. And then we have patients lying in bed that maybe at best have their mouth swamped with a tooth that I don’t know about you but if I went even just a weekend, swabbing my mouth with the tooth that they would not be pretty, you know, not smell pretty either.

But by using a toothbrush, toothpaste, bring that section in there and cleaning not just the teeth but you know the roof of the mouth, the tongue the beautiful cavities, we are significantly significantly reducing their chances of developing aspiration pneumonia. I cannot emphasize enough how important this is for our patients with teeth and without teeth. Because people without teeth they still have secretions and bacteria building up and we need to brush it just as we do People with teeth,

Kali Dayton 30:01
You’re preventing mortality. Right? When does aspiration pneumonia contain septic shock? You’re, yeah, you’re preventing death.

Suzanne Ball 30:10
And I think it’s important actually, to view this more as infection prevention. So I think oral care kind of gets forgotten. But in reality, it’s infection prevention. And it shouldn’t go hand in hand with all of the other measures that are being used in the ICU to prevent infection. And so we can look at it as having multiple benefits here. So not only is it quality of life and dignity for the patient, but infection prevention.

And it is so much more valuable than peg placement. Because as I said, before, we know that pegs don’t prevent aspiration, because guess what, even if the patient is not eating and drinking, they still have those secretions building up in their mouth, and they’re gonna go somewhere. And if they have dysphasia, there’s a good chance they’re going to end up in the lungs.

Kali Dayton 31:03
Yeah, absolutely. And how, how much less? Would we be seeing pigs if we were mobilizing patients to begin with? How much would that compensation change, if we expected someone to be strong enough to control their breathing, swallow and do those things within a week or two, rather than the following months after being excavated or tricked?

Suzanne Ball 31:27
Absolutely. And, you know, I’m probably talking a lot about things that people don’t think SLPs really work with, for example, like the respiratory system that plays such a huge, huge role in swallowing and swallowing and safety, we need to do everything we can before any potential pneumonia can occur, oh, when a patient gets deconditioned, their muscles might not be strong enough for them to cough up aspirated material.

So we’re adding just thing after thing that’s working against the patient, by not allowing them to be mobile, and sedating them. So like I said before, you’re really creating the perfect storm for an infection to breed, because we’re letting bacteria grow in the mouth. And then when that bacteria goes down into the lungs, the patient can’t independently expectorated.

Kali Dayton 32:27
Right, right, they don’t have a functional diaphragm, exactly the right muscles to do that.

Suzanne Ball 32:33
And then you add sedation on top of that, and now you have a compromised cough reflex in a disc coordinated swallow. So even if they could cough, now, maybe they don’t sense it. And so their body isn’t going to do that natural response, which is coughing. So rather than fighting all of these things backwards, we can use what we know, to prevent it prophylactically with mobility, increasing mobility, decreasing sedation, and really hammering in on the oral care.

Kali Dayton 33:05
Oh, you make so many good points. And it just reinforces the whole theme of the podcast, right? That, just as you said, mobility and avoiding sedation, prevent patient harm. But you’re painting out this awesome picture of how it prevents aspiration, and therefore aspiration pneumonia, and therefore, re intubations prolong time on the ventilator longer time in the hospital, more infections, complications and death.

So if we’re not implementing these protocols, we are setting patients up, as you said, for all of this harm. And how much more could we be doing if we really incorporated the experts such as SLPs that are specialized in this knowledge and can help us hold to be held accountable for our oral care can support us in doing that, and, and really make sure that patients are safe and progressing and working towards the goal of walking home from the ICU?

Suzanne Ball 34:04
Absolutely. I actually have a case study that I thought was really fun. So I wanted to share it, please. So there is a man who entered the hospital with COPD exacerbation. He had a history of smoking. So he’s admitted to the ICU and his initial initial chest X ray revealed that he had atelectasis and bilateral infiltrates. So over the course of his first 48 hours, he received intensive therapy.

This just wasn’t PT. It was PT ot SLP pulmonary rehab like respiratory therapists. By the end of the 48 hours, they did a repeat chest X ray. And it came back unremarkable. He no longer had atelectasis and his infiltrates for clearing up that is just 48 hours. So even if you haven’t used all these tools to prevent this, we know that At least can halt and hopefully reverse, you know, the disease progression that’s occurring in the lungs through mobility in therapy.

Kali Dayton 35:08
Okay, now you have been thinking, we’re doing a lot of high flow and a lot of BiPAP. Right now, obviously, in our COVID units, I have a lot of concerns about our mobility practices for those patients that are not yet intubated, and I really feel like we set them up for intubation, by making them bedridden. And in some places, it’s protocolized, that you cannot get someone out of bed if they’re on a high flow. Yep. How do you as an SLP feel about that? How do you see that?

Suzanne Ball 35:43
Well, I mean, that it’s just mounting effects. So if this patient, like we said, is not mobilizing, not using their muscles becoming further decondition, enhance their lungs, or as well, they, they will experience this disease progression in their lungs. And that impacts their breathing, and thus, their swallowing, and even their communication, it’s pretty hard to talk when you’re short of breath. And when you’re constantly, you know, coughing up secretions.

So, you know, a lot of times I’ve seen SLPs say that patients need to be NPO, because they’re not able to manage their secretions. But mobility can facilitate, you know, maximal inspiration, filling up those lungs, we know that movement simulates alveolar ventilation. Not only that, body positioning can impact the gravitational effects on secretion, drainage and mucociliary transport. So just by sitting a patient upright in bed, you’re changing the way they’re, you know, secretions and mucus are being moved and expectorated. So basically, even just sitting your patient up in bed, or dangling them at the bedside, you’re helping protect their lungs and further protecting their swallowing function.

Kali Dayton 37:08
And playing them this whole aspiration pictures. Well, I’m having a flashback to a shift was working and telemedicine. I mean, this is a common occurrence. But I remember this specifically with a COVID patient in a rural hospital. And I, you know, popped in on the camera and saw 75 year old grandpa semi reclined in the bed on high flow 60 liters eating breakfast with a tray next to him and I almost climbed through the camera.

And the facility didn’t think anything of it, and never seen him no one evaluated, which for me, most patients on high flow, I want speech in there telling me if they’re still safe to eat, if they can maintain their stamina in order to eat enough, or do they need a feeding tube so that we prevent further atrophy, risk of aspiration and set them up for intubation.

Suzanne Ball 37:59
I mean, anytime you’re introducing supplemental oxygen and changing the way that the pressure is moving, within the oral pharynx, you have the potential to impact swallowing. So just as you’re doing, you know, I think an SLP needs to get in there right away. And just because someone’s on high flow doesn’t mean that they can’t eat and drink. But we do know what we can do to protect them before they’re being assessed during and after, which is again, that oral care, but body positioning.

I don’t eat my dinner laying flat back. So a lot of times when I go in to see patients I’m, you know, wanting to see how they’re being fed. And oftentimes, I’m seeing that, you know, they’re reclined at 45 degrees, and they haven’t had their teeth brushed before eating and drinking. So if I could tell people to do any two things, it sit that patient up and clean their mouth before and after they’re eating and drinking.

Kali Dayton 39:02
Yeah, there’s a hard rule now I can walk in, I see that you do not eat in bed. You don’t if unless you get up into the chair, you don’t get to eat. That’s just that’s just the way it is for everybody, no matter their status, motivator. Right, right. And if they’re too weak to sit up in the chair, they’re more or less likely to week to eat. And that’s what we need to work on.

And so I think when we have patients even before they get intubated, if we’re working, where we’re trying to prevent that you’re making this case as to why we need to get ot PT SLP into those patients rooms, like upon admission that they’re being admitted on high flow and BiPAP. Or even on the ventilator, they just need to be in there, right away. And as soon as someone’s excavated, I love to have speech and they’re saying, what do we need to do? Were they out with their swallow and be working with them and their cognition right away? Do you ever do mocha scores on patients?

Suzanne Ball 39:58
Yes. So So, you know, a lot of SLPs use the Moca because it is free, and it has some decent standardization, the only pitfall there is that, you know, it would standardize on a specific population. So, as an SLP, anytime I’m looking at cognition with a patient, I need to be really looking at who they are as a person, you know, what’s their first language?

How many languages do they speak, what’s their educational level, what’s their normal cognitive load, you know, when they’re at home and at work? What’s really expected of them, because that all of that can impact somebody’s score on a cognitive test. And we need to be cognizant of the fact that not everyone is a college educated person from a certain racial demographic, with a certain, you know, ses status. So while the standardized measures are great, again, just further driving home, how important it is to look at the patient as an individual person.

Kali Dayton 41:09
Absolutely, and just testimonial to the component of your professor of your discipline in the cognition of patients, because I’ve had patients that they can pass a cam score, but it just feel like they’re not at baseline. And so that’s why I rely on the SLP to go in and tell me, where are they really? And do they need follow up? to rehabilitate their cognition if they’ve had delirium? Or are they okay? And do we feel like they can resume their life and jump back into the profession and, and really their their normal life? And SLP is, is that key component to say, they still have some deficits, they need to follow up, and then we know how to support them and how to restore their whole lives.

Suzanne Ball 41:56
Absolutely. And, you know, nursing can absolutely have a role in this, because, you know, cognition plays a role in delirium management. And, you know, further we have been people’s cognition. But oftentimes, you know, I see that some patients might get missed, because if you can go into the room and ask someone, their birthday and their date of birth and who the president is, a lot of people can get by with that information.

But I want to urge nurses and physicians to use something that’s a little more comprehensive, like, the orientation long, or we call it the O log. And it has many more questions where you’re asking the patient about where they are, what happened to them, you know? And if they can’t answer those questions, the test helps you give them cues and prompts to really see you know, where they’re at, so you can give them logical cues. For example, if you are asking a patient, what day is it today, and they can’t seem to get it? And you know, today is Thursday.

So I could say, Well, yesterday was Wednesday. So today is and give them a little prompt. And by doing something like that, not only are you facilitating frequent reorientation with them, hopefully helping to minimize delirium. But you’re also seeing how to best communicate with them. Are they understanding what you’re asking? And are you understanding what they’re trying to communicate? So when we’re talking about patient wishes, and what they want, you’ll have a better understanding of do they really know what’s happening to them and the implication of their decisions?

Kali Dayton 43:44
Yes, and that is, a lot of the circumstances in which I’ve had SLPs do smoke scores is to know or to get some sort of further insight into how how much responsibility can we give them for decision making? Because they can autonomy is so important, and we want to make sure that they are able to participate in those decisions. Yeah, you guys are such a key role in the ICU, I hope that our culture continues to transform to allow you guys an increasingly bigger seat at the table, and a spot at the microphone, anything else you’d share with IC community?

Suzanne Ball 44:23
Sure. So I have just two things. I want to talk about some SLP myths, and then nonverbal communication, and then I’ll be done. Love it. First about the myths, you know, SLP is actually a pretty new field. Nursing has been around much longer than us. And we haven’t always had the best science because we’re new and, you know, working with humans, you have to get through IRB boards to do research.

So in the beginning, we’re finding out that we offer waited on some premises that weren’t always accurate. And I think unfortunately, that has trickled down into nursing and medical management because you’re trusting us, which is, you know, lovely that we can have the inter disciplinary teamwork and trust together. But SLPs need to do a better job of dispelling some of these myths. And there’s three that I want to address.

One is the chin tuck. So, oftentimes, I’ve seen, you know, nurses with a great heart that think that they’re protecting their patient, by saying that a patient should tuck their chin at the bedside, because they might be coughing, or in general, they’re just worried about the patient aspirating. Now as an SLP, because I have done video fluoroscopy, I have actually been able to visualize myself that the chin tuck does not always prevent aspiration, and sometimes even facilitates it. So these body positioning and compensatory strategies really are patient specific, because you are changing the way that the anatomy and the physiology is working inside somebody. And as we all know, it’s a little bit different for everybody. So if we’re going to recommend something like that, it truly needs to be visualized with MBSS, or fees. So we can visualize actually what’s happening with the swallow.

You know, I like to use the example with physical therapy. If I was a patient, and I went to a physical therapist aside, I fell off my bike, my arms hurting, it looks kind of funny, I would hope that they would not do therapy with me, and just treat my pain without having done an x ray, and sustain the swallowing. If that if we’re asking a patient to use a chin tuck, that tells me and we’re already assuming that there’s some kind of deficit or some kind of dysphasia. And if we think that the patient is having a swallowing problem, let’s do our due diligence and really see if that is the case. And if they do have dysphasia, we want to make sure that what we’re recommending is actually helping, because we don’t want to introduce maladaptive behaviors. So that’s one of the myths.

The second myth is thickener usage. So thickening liquids has a time and it has a place. However, it is just like postural changes, like the chin tuck, it should not be used unless you’re able to prove that it is actually doing what you want it to do. So for example, we know like everybody aspirates, our body is able to get rid of the aspirator material. However, when we introduce thickener, if a patient asks for its thickener, it’s a lot different than aspirating and water, you get that sludge and your lungs, it’s harder for the patient to get out. And it just kind of sits in there. And some studies have suggested that can actually increase the potential for developing pneumonia.

Also, another fun but sad fact about thickener is that just because a patient isn’t coughing when they’re using thickener doesn’t mean that they’re not aspirating. So, for example, if you’re at bedside and a patient is coughing within liquids, and then you put some thickener in it, we’ve essentially just masked symptoms of a potential problem without identifying if there truly is a problem such as dysphasia. And without truly knowing if the thickener is mitigating that problem. So chin tuck or postural movements and thickener. Always make sure you’re talking to your SLP and a thorough assessment is done first.

And then third myth, coughing, coughing has been villainized I think coughing is great, because to me, it’s showing me that the patient, if they are coughing, because of aspiration, they have an intact sensory response. And how amazing is that? That now we can just focus on all the other aspects of swallowing and not also be worrying about Wow, they can’t sense what’s going into our lungs. So coughing can be a sign or symptom of dysphasia and it can be a sign that something is going into the airway and an absolutely warrants an assessment.

However, some medications can cause coughing, you know, when a patient has been NPO they have buildup of secretions in their mouth, but they’re also in their pharynx and I wouldn’t be coughing and gagging on that stuff, too. If I had all that stuff in their junk in there. You You know, the mucus and secretions. So those are, you know, three, I guess you could call them pet peeves of mine. And lastly nonverbal communication.

So, an SLP role, there’s something called AAC, which is augmentative, and alternative communication. And that ranges from low tech, from things such as you could even just have a piece of paper with yes and no written on it to devices that are like tablets with eye gaze. So you just have to look in the direction of the word and Celexa and it says it for you. Now, you know, not only in our hospital, short staff, but they have to think about money.

So a lot of them can’t afford high tech, AAC devices. But as a nurse, and as a therapist, we can very much use low tech AAC, to communicate with our patients or for them to communicate with us. But something that’s really important here to understand is that we need to establish a method to know that that we’re understanding what the patient is saying. So we need to ensure that there is validity in what we’re doing.

By, you know, testing. So you’re not just gonna go in there and say, Oh, the patient looked at the Yes. And the patient looked at the No. Or maybe they pointed out the Yes. And the No. We can ask questions, egocentric questions, so ask questions about the patient. Or we can even get more complex asking questions like, okay, is the sky green? Versus is the sky blue? And we want to make sure that they’re really understanding our yes, no questions, so that we’re not misinterpreting what they’re trying to say to us.

And some other things to note, which I’m sure you’ve seen, patients can talk non verbally, or communicate non verbally through, you know, hey, shaking their head giving us thumbs up, thumbs down. And, you know, pointing to these picture or word communication boards? And it doesn’t just have to be yes and no, we can build it up have more quadrants where they can answer our WH questions, which are the what the when the where, the why, and the how, you know, when we’re going into a patient’s room, they deserve to know what is happening to them.

And we can show them pictures and allow them to help us guide them in their care, you know, are they having pain can can they point to the word that says pain, and then we can kind of go through and rate that with them or find the body part that’s hurting them. So there’s so many applications for low and high tech AAC. And I promise you, if you bring up that word to your SLP, and your facility, they will be happy to find resources for you to have on the floor for every patient room. And I can send you a couple of PDFs of some that I like to use.

Kali Dayton 52:48
I would love that. And I also have a good friend that we to talk. So he’s offered to give anyone that wants a good deal on a subscription to their, their program as well, because that should be as we’re humanizing ICU, and we’re trying to keep people more awake and involved in their care, you make such a good point, we need to have a way to communicate to whatever level they can in that moment. And our SOPs are the gatekeepers of that in a lot of ways.

Suzanne, thank you so much, I’m thoroughly convinced that we should not be without SLPs in the ICU, you have completely compelled me to advocate for that more. And as we are trying to revolutionize our ICU and be more evidence based and provide more humane care, we cannot do that without SLPs right alongside of us. We are all working on this together. And thank you for all that you do and all that you bring to the table and your whole discipline. And I’m excited to see what happens as we continue to collaborate.

Suzanne Ball 53:52
So Well, thank you so much. And I so appreciate you making this podcast. You know, every chance I get. I’m trying to tell people to listen to it because I think this is invaluable. And if we can have this adopted, I think this concept adopted, I think we’re gonna see a reduction in pegs, better patient outcomes, and you know, helping people getting back to their lives the way they once were. And what more can we really want.

Kali Dayton 54:21
Yeah, that should be everyone’s goal. But we have we need each other to get there. And everything that you’ve referred to as far as studies will be on the blog as well. Thank you so much for providing those.

Suzanne Ball 54:31
Absolutely. Thank you.

Transcribed by https://otter.ai

 

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