Today was my first day at a new practical. I am doing the next 6 weeks at a private hospital here in Pretoria. It's probably going to be a challenging few weeks, but hey, that's what learning is about, isn't it? :)
Where I come from, the private hospitals are more or less what you would expect a hospital to be like - big, open, cold spaces where you can almost feel the sickness and disease lingering in the air. I usually feel chilled to the bone when I walk through a hospital, like I should wrap my arms tightly around my body to protect myself from whatever is in the air (and from the people). But Today I was amazed that you actually get hospitals like this. It was clean (no not just clean, spotless!!), it didn't feel infected, it was organized, and the facilities are amazing. There are no more than 3 beds in a ward, the nurses are all friendly, and everyone is clued-up about all the patients. They have a good system going. Oh, and best of all, the patients are put into the wards according to their condition, they aren't just shoved in wherever there is space.
So this practical that I'm doing is a neuro-prac. So I'll be seeing patients with all sorts of neurological problems related to speech. The unit that I'll be working in is one of 5 stroke units in South Africa, so my client basis will mainly be stroke patients. Today was just an orientation to the hospital, and observation of a few therapy sessions with the Speech Therapists running the practice.
As I have explained in a previous post, Aphasia is generally known as "word finding difficulties". More specifically, it involves damage to one, or all, of the language area's in the brain. What this means is that certain aspects of language are affected in various ways, the planning, processing, or execution of language functions. Two of the main types of Aphasia that we get are Broca's Aphasia, and Wernicke's Aphasia.
In a nutshell, Broca's Aphasia is when a person understands what he/she hears, or better said - the language he/she hears or reads, but they have difficulty expressing themselves through use of language. So for example, if a person were referring to a door, they might not know the word "door", and would use circumlocutions (round-about ways of describing the word). They might say "this thing", and point to the door, or "that thing with a thing that you turn to open it", or even something like "that thing that you use to go into the house".
Wernicke's Aphasia, on the other hand, is when a person doesn't understand what they hear or read. They can't process the language, and thus don't understand when people speak to them. These individuals usually don't make sense when they speak. They either talk rubbish, but with existing words, or they speak using words or phrases that have no meaning whatsoever.
Apraxia is motor planning difficulties - inability to plan, and thus execute, movement.
You seldom get people who have a single diagnosis. They usually co-occur with another diagnosis, for example Wernicke's Aphasia with a component of Apraxia. They seldom occur in isolation.
So today we observed a patient who had a stroke, and was diagnosed with Wernicke's Aphasia and and Apraxic component. I am not familiar with the history of the patient, so I'm not sure how long ago the stroke occurred. The patient was a female, and is currently receiving Physiotherapy, Occupational Therapy and Speech Therapy.
It is evident that there was brain-stem damage from the stroke, as the patient is unable to swallow. In a normal functioning individual, if you get some sort of bolus in your mouth, whether it be a liquid or a solid, no matter how thick, you would either chew and swallow, or just swallow it. What I found really interesting with this patient, is when we put yoghurt or water in her mouth, she could close her lips, and look as if she is going to swallow, and then suddenly she would open her mouth and stick out her tongue. This is where the Apraxia comes in. She can't plan the movements of chewing, or moving her tongue around. Apraxic patients generally stick out their tongue when trying to plan any oral movements. I can't say why though.
This patient can't swallow any food, and she therefore aspirates when the food does enter the throat, so she is fed through a naso-gastric feeding tube.
The Wernicke's Aphasia (WA) in this patient was such a perfect case of WA. It is very rare that patient's have such a prominent case of WA, and the diagnosis is usually very difficult to make, but in this patient it is a perfect Wernicke's Aphasia. She would look at you when you talk to her, and look as though she is listening, and then she would start nattering off in some non-existing language, sometimes in Sotho. She say's whole long utterances, and then looks at you waiting for you to respond. Sometimes it would seem like she understands what you are telling her, because she would give a very long "oooohhhhhhh", and then laugh, but then she would say something unintelligible. You can see that she understands the function of some objects, like a brush, because she showed that it's used for brushing your hair, and a toy banana that she wanted to eat. But she can't tell you what is going on in her head. She reads facial expressions very well. She can see when you don't understand her, and will then repeat herself, and get teary and upset, but she doesn't understand why you don't understand her, because to her it all makes sense.
In therapy, all that you can really do is try and work on memory and vocabulary, and her understanding of words, and hope for some improvement somewhere along the line. Because only when a patient starts realizing that they aren't doing something right, will they show progress. It's such a hopeless feeling sitting in front of a patient, not knowing how much they understand you, and now knowing what they are trying to say. Especially when they get upset, and you can't sooth-talk them, or comfort them in any way. It's a horrible feeling, but all that you can do is hope for the best.
Xxx
