February252002

Speech-LanguagePathologist.org

We are pleased to welcome Julie A.G. Stierwalt, PhD, CCC-SLP, as our

guest speaker for tonight's SLP chat on Monday, February 25, 2002.

Dr. Stierwalt will lead us in a chat about The SLP's Role in the

Medical Setting. She is an Assistant Professor in the Department

of Communication Disorders at Florida State University where she

teaches courses in neurogenic disorders, structural-based communication

disorders, dysphagia, and medical speech pathology.

Dr. Stierwalt has numerous publications and presentations in these areas

as well as with issues related to the use of technology in higher education.

<Robin> Welcome Dr. Stierwalt! Thank you for joining us tonight!

<JulieStierwalt> Hello Robin, Thanks for the invitation!

<Robin> We are chatting tonight with Dr. Julie Stierwalt about the SLP's

role in the medical setting.

<Adrienne> think- are you planning to work in the medical setting?

<Ithinkican> No...I'm currently at a placement there and I'm finding the

transition from kids difficult to adjust to.

<JulieStierwalt> I think that is a common concern

<Ithinkican> That's good to know!

<Robin> Dr. Stierwalt, could you give us a general idea of the type of

settings and caseloads an slp would expect to find?

<JulieStierwalt> There are many roles - settings in the medical arena that

are unfamiliar and should I say...scary?

<angiefsu> Are there any real areas of research in the medical speech-path

setting that need further evaluation?

<JulieStierwalt> Every area that I can think of in the medical setting has

active research from the ICU to long term care.

<JulieStierwalt> Let's begin with ICU

<Robin> Yes, lets start with ICU...what would the SLP's role be?

<JulieStierwalt> In ICU the role is mostly consultative.

<JulieStierwalt> Referrals come with the intent to set up an optimal

communication system or establish a safe swallowing program.

<JulieStierwalt> Many folks in ICU are on ventilators.

<JulieStierwalt> Or at times, our role is to establish whether or not

individuals are capable of communication with regard to comprehension

as well as expression.

<Ithinkican> How can we accurately assess comprehension at this stage?

<JulieStierwalt> Many times, in reviewing the medical chart you will see if

they have established a form of communication.

<JulieStierwalt> Sometimes it is eyeblinking, etc.

<JulieStierwalt> You begin assessing comprehension with easy questions.

<JulieStierwalt> The main goal is to establish a reliable system, often just

yes/no because they are so ill.

<JulieStierwalt> They often can't handle a lot of communication.

<JulieStierwalt> Any other questions regarding ICU?

<Adrienne> would you provide tx in ICU? or just diagnostics?

<JulieStierwalt> It really depends on the patient.

<JulieStierwalt> Often if they can tolerate it, you can do some tx (treatment).

<JulieStierwalt> You have to carefully balance expectations with what they are

capable of.

<Adrienne> What is your opinion about withholding tx until after spontaneous recovery?

<Adrienne> With medicare cuts, some have suggested optimizing the tx time by waiting

until after spontaneous recovery.

<JulieStierwalt> There are several schools of thought around that issue.

<JulieStierwalt> Martha Taylor Sarno did a controversial study MANY years ago that

found recovery was greatest for individuals with global aphasia more than

6 months after the stroke/neurologic event.

<JulieStierwalt> But in my mind, it doesn't make sense to withhold treatment.

<JulieStierwalt> Following injury there is a period of time when there is what is called

"synaptogenesis" or the birth of new synapses. The brain's method of healing.

<JulieStierwalt> In order to optimize this state, it is important to begin tx early

<Adrienne> I see

<angiefsu> Is there a time frame on that period? How long does the recovery last?

<JulieStierwalt> Now, depending upon the severity of the injury and many other things

it might be best to let the patient fully stabilize prior to initiating a full

complement of rehabilitation.

<Adrienne> What is the average length of an ICU stay?

<JulieStierwalt> It varies, but typically only a few days.

<Robin> What is the role of the SLP once the person is stabilized and out of ICU?

<JulieStierwalt> The next level of care is acute care.

<angiefsu> Any area particularly exciting to you?

<JulieStierwalt> Angie, I think it would have to be this one, acute care.

<Adrienne> and why is that?

<JulieStierwalt> In this setting, the SLP can do a more comprehensive assessment.

<JulieStierwalt> The time frame is still minimal, only a few days usually.

<JulieStierwalt> Our role here is primarily as a diagnostician.

<Adrienne> Would you test someone again if you did some in ICU with them?

<JulieStierwalt> Usually your assessment in the ICU was rudimentary.

<Acgoodman> How much actual treatment is done by us?

<Adrienne> Would the same slp see patients in ICU and acute, etc?

<JulieStierwalt> Depends on the hospital and how many SLPs you have on staff.

<JulieStierwalt> In the acute care setting you want to assess patients to see what

their prognosis looks like and what the next step should be.

<Ithinkican> I find this particularly difficult as a student in the acute setting

<JulieStierwalt> Yes, you really have to think on your feet.

<JulieStierwalt> That is a skill that certainly takes some practice, but I was very

excited by it as a student.

<JulieStierwalt> You see some fascinating things

<JulieStierwalt> Well, I'd have to say that about every aspect of the medical setting.

<Ithinkican> I think as you start to see where people go after acute you can start to

see that bigger picture.

<JulieStierwalt> That is accurate think-

<JulieStierwalt> It is boggling when you think of all the options.

<JulieStierwalt> And that they want YOU to make the decision where the patient should go

<Ithinkican> That's for sure! Hard to get them all straight and refer on from there!

<angiefsu> Can you describe one of your more fascinating cases?

<JulieStierwalt> Wow, I have had some interesting cases.

<JulieStierwalt> What type would you like to hear about?

<JulieStierwalt> Dysphagia, Neurotrauma...

<angiefsu> Just one of your top , I guess...

<Adrienne> Something unique to hospital setting?

<Ithinkican> Dysphagia is mainly what I've been seeing!

<JulieStierwalt> Okay

<JulieStierwalt> I'll give you an interesting dysphagia case.

<JulieStierwalt> I had a patient who attempted suicide by drinking Draino.

<JulieStierwalt> Burned all the way through...

<Ithinkican> wow!

<angiefsu> whew!

<JulieStierwalt> She survived but eating was no longer possible.

<JulieStierwalt> On oral mech, you could see the smooth scar tissue on the velum and

pharyngeal walls.

<JulieStierwalt> Absolutely no peristaltic action to help the food down and no help from

the epiglottis which was burned into one position.

<Robin> oh thats bad

<JulieStierwalt> She had to suction even saliva because she aspirated it.

<JulieStierwalt> She wanted to eat SO badly

<JulieStierwalt> Nothing seemed to work for her with the documented treatments.

<Robin> how old was she?

<JulieStierwalt> In her late 40s

<JulieStierwalt> So they tried something a bit unconventional.

<Ithinkican> It sounds like an "unusual" case

<JulieStierwalt> They built her a new esophagus!

<Ithinkican> WOW!

<JulieStierwalt> It too, was badly burned

<Ithinkican> How did they do that?!

<Adrienne> geez

<JulieStierwalt> I'm not sure about the tissue that was used.

<angiefsu> did it work?

<JulieStierwalt> But one day I went to Dysphagia rounds and they were

looking at a Videofluoroscopy.

<JulieStierwalt> The new esophagus did not have the contractile properties of course

so she had to move her body and utilize gravity to get it to her stomach.

<angiefsu> but... she could eat! and that was her goal...

<JulieStierwalt> Yes

<angiefsu> wow

<Ithinkican> wow!

<JulieStierwalt> When I treated her in acute care we ended up with only being able

to taste things with her head in a tucked forward position

<JulieStierwalt> and then once she tasted it she had to spit it out.

<Adrienne> oh man

<eeg> what kind of tx techniques did you use for such an unusual case?

<JulieStierwalt> Well diet modifications didn't work.

<JulieStierwalt> There was no intact tissue to implement thermal stimulation.

<JulieStierwalt> Since the epiglottis was nonfunctional and pharyngeal contraction was

minimal she aspirated everything.

<Ithinkican> yikes!

<JulieStierwalt> The worst case of aspiration I have ever seen.

<Robin> Dr. Stierwalt, tell us about what the role of the SLP is in the rehab unit,

after acute care.

<JulieStierwalt> In the rehabilitation unit lengths of stay are longer.

<JulieStierwalt> Here is where you can really be the "therapist".

<JulieStierwalt> You might work with patients for 3-4 weeks if you are lucky.

<JulieStierwalt> You really get to know the patients and get excited about the progress

they make

<Adrienne> 3-4 weeks... how often per week?

<JulieStierwalt> daily or more

<JulieStierwalt> Sometimes you might see them in individual tx

<JulieStierwalt> then also in group tx.

<JulieStierwalt> Often also at mealtimes to work on dysphagia issues.

<eeg> Is it typically more group than individual?

<JulieStierwalt> Actually in rehab I would say more individual than group, don't you think Robin?

<Robin> Yes, I think more individual than group...

<JulieStierwalt> At least that has been my experience when I worked on the TBI team in rehab.

<JulieStierwalt> All the patients had group tx in the mornings which was based on cognitive rehab

then they followed up with individual discipline specific txs in the afternoon.

<brenda> On a different note, I am preparing to apply for a CFY internship, would I have better

luck with a skilled nursing facility or a hospital? Or would they not accomodate a student

who does not yet have their license?

<JulieStierwalt> brenda, it depends on the hospital and their staff.

<JulieStierwalt> The biggest issue is the supervisor.

<JulieStierwalt> You would want to have someone close at hand if possible while you get

used to the setting.

<JulieStierwalt> In longterm care they often don't have a lot of therapists on site.

<JulieStierwalt> But I know a LOT of people who have done it that way.

<JulieStierwalt> It's just that some people are uncomfortable in the medical setting when they first get

going if there is not a supervisor readily available.

<JulieStierwalt> So I guess it is an individual thing as so many things are!

<angiefsu> Any advice to the students considering this area of speech path?

<JulieStierwalt> The medical setting has a wide variety of settings.

<JulieStierwalt> If you like a fast pace and being constantly challenged then ICU and acute care are

for you!

<angiefsu> )

<JulieStierwalt> Rehab and long term care settings are a little slower paced but also special

in that we get to be the clinicians that we love to be.

<brenda> Yes, I 'm aware of the supervision factor. That was a concern for me last summer while I was

doing my externship. If I have liability insurance, it sounds like a longterm care facility

offers a better chance based on the # of therapists.

<JulieStierwalt> brenda, it is really what you are comfortable with.

<JulieStierwalt> Be sure that you have a plan with the employer before you accept a position.

<Robin> It really depends on the facility, brenda. Some rehab hospitals have more staff and may have more

CFY opportunites.

<JulieStierwalt> I know students that have accepted positions and then went out to long term care

facilities with very little back up and they were asked to make pretty critical decisions.

<JulieStierwalt> That can be a little unnerving in a CFY year.

<Robin> There are many more dysphagia cases these days.

<JulieStierwalt> Yes, and those can be pretty medically touchy.

<brenda> I can honestly say that ICU and acute care were very intimidating for me. I will apply

to both and see what happens. What do you mean by a plan with the employer? In terms of caseload/#

of hours/supervision? Do I provide that in writing or do they tell me?

<angiefsu> As a student, I'm pretty intimidated by dysphagia.

<eeg> Me too!

<Ithinkican> I definitely agree!

<JulieStierwalt> You'll feel better after you take the coursework.

<Adrienne> I'm not even sure I pronounce it right!

<eeg> me either!

<angiefsu> you guys!

<Robin> At least you will have a course in dysphagia...many of us oldtimers learned on the job

and in continuing ed courses.

<JulieStierwalt> Yes, I took a workshop, because it made me so nervous.

<Adrienne> When an slp is discharging a pt. from rehab- what are typical recommendations?

<JulieStierwalt> Following rehab there are a number of options.

<JulieStierwalt> Patients might go home discharged from tx.

<JulieStierwalt> Or they might go home and come back on an outpatient basis.

<JulieStierwalt> Other alternatives include long term care.

<JulieStierwalt> In long term care there are several different "levels" as well.

<JulieStierwalt> Skilled placement is where you send patients who still need round the clock attention.

<JulieStierwalt> For example they still have tube feedings.

<JulieStierwalt> Sub-acute rehab is a level that has therapies but not typically on a daily basis.

<JulieStierwalt> It is confusing, but when you get into it you learn quickly and this is such a rewarding

setting both professionally and personally.

<JulieStierwalt> Of course I am COMPLETELY unbiased

<brenda> What is meant by sub-acute rehab? Is this still part of a hospital or a separate facility?

<JulieStierwalt> Typically long term facilities will have sub-acute beds, but some hospitals will as well.

<JulieStierwalt> A wing of the hospital or facility or a floor, or ward.

<JulieStierwalt> It varies quite a bit.

<JulieStierwalt> Sub-acute is in greater demand these days though with decreasing hospital stays.

<Robin> There is also home health where tx is provided in the home.

<JulieStierwalt> Yes, thank you Robin.

<Ithinkican> home tx?

<JulieStierwalt> Home health care occurs with those patients who can't make it to the hospital and

are homebound for whatever reason.

<JulieStierwalt> Maybe their spouse can't drive or they are too fragile or the weather is not

cooperating (THINK).

<Robin> We have been chatting for almost an hour...are there any further questions for Dr. Stierwalt?

<booms> I have no questions but I enjoyed just reading along. Thank you all.

<Ithinkican> No questions left! Thanks for the answers!

<Robin> Thank you for your time and knowledge, Dr. Stierwalt

<JulieStierwalt> You bet, any time

<Robin> Thank you all for joining us....Goodnight!

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