My first ever blue-dye test

 15 May 2018

Growing up, I was that little 5 year old girl who used to catch bugs in a little transparent jar, and examine them through a magnifying glass. It excited me to discover new animals and organisms, and examine them, play with them… make new friends. As I grew older, and learned that this was not the norm, that these things could potentially be harmful or gory, and I became cautious of these things – afraid of bugs, disgusted by touching unusual fluids and objects, and scared of blood. I became the normal teenage girl who squeals and screeches when touching strange textures or when bugs come too close.

As a Speech Therapist, we see all kinds of things. Working in a hospital exposes you to things not many people would ever imagine –bodily fluids, bad breath, infected wounds, dirty people, exposed genitalia, burst catheter bags, to name a few. One thing is for sure, I take my hat off to the nurses.

On this particular day, I had a patient who was diagnosed with myasthenia gravis, had a tracheostomy tube in situ, and was dependent on a ventilator to breathe. Myasthenia gravis is an autoimmune disease in which a weakening of the skeletal muscles responsible for breathing and movement occurs. Essentially, an overall weakness occurs, making breathing, moving and even blinking or opening your eyes difficult. The result of this weakness often leads doctors to insert a tracheostomy tube (see the image below) – a tube inserted into the lower soft part of the throat, that helps keep the airway open and allows for easier breathing. This patient was dependent on a ventilator because he was unable to breathe on his own.

   

This patient was referred to Speech Therapy to do a swallowing evaluation on him – is he allowed to eat orally? He had a naso-gatric (NG) tube in place through which they were feeding him. This is a tube that is placed through the nose, down into the stomach.

 

Generally, when we do swallowing evaluations, we start with a bedside evaluation and end with a videoswallow at X-Rays. A bedside evaluation here was our only option, as this patient was on a ventilator and we could not transport him to x-rays. Often patients who have tracheostomy tubes in place have a decreased sensation in the airway, so the natural cough reflex when something enters your airway might not be there. This makes a bedside evaluation not as reliable as a videoswallow. In these cases, we do what we call a blue-dye test. Blue is the only colour not excreted by the body, so we take blue food colouring and mix it into water and sometimes yoghurt, making it a hideous bubble gum-blue colour. The patient drinks 3 sips of blue water, and we then suction their lungs through the trache to see whether any of the secretions are blue, in which case we know that they have aspirated.

I am the type of person who I think you could term as physically, physiologically and emotionally sympathetic. I can physically feel what other people must be going through, and I get similar sensations to what people describe they are experiencing. Now because I had never done a blue-due test before, my boss had come along to the swallowing evaluation to teach me how to do the test. This patient was in isolation for an infectious virus, so we dressed up in the appropriate attire – gown, mask, head cap, gloves, shoe protectors, and in we went. My boss explained the procedure to the patient, and began the study. He took the sips of water, and they waited a couple of seconds. When that suction pipe went into his airway, he started coughing. Imagine having something shoved into your airway and kept there, you are unable to get it out by coughing, so you cough to the point where you gag from the sensation.

The look on this man’s face whilst they were suctioning… his face went instantly red, agony painted like a canvas in his expression, and coughing, coughing, coughing. Coughing until he gagged, in which case vomit had come up through his NG tube. It was then that I could no longer watch. I could feel what he was going through… the pipe being forced into my lungs, being unable to get it out. Tears streaming down my face purely from the sensation which I wasn’t really experiencing, I stepped outside. This was where my boss found me after the swallowing assessment  – standing flat against the wall, head tilted back breathing deeply, mask in hand having torn it off my face, and my gown (which was resting just a little too tightly against my throat) half torn off my body.

Being a Speech Therapist, it is a part of my duty to perform this test, as no one else is able to do this. I have since taught myself to zoom in on the suctioning pipe and focus on finding that speck of blue, instead of allowing all other environmental stimulation to register in my brain… The patient choking, slime coming out of the suction pipe, agony across the patient’s face, or any other sounds that might cause an unfavorable reaction on my part. I can proudly say that I have successfully mastered the ability to independently perform a blue-dye test.

So you learn to desensitize yourself to experiences which may not be most pleasant. A very specialized skill to have I’d say…

Later 😊

Xxx

Arriving for a videoswallow, and finding it already finished – by who?

27 April 2018

One of the most prevalent conditions we as Speech Therapists work with, is dysphagia. Well, that is adult neuro-therapists. Coming out of varsity, I was ignorant to the astoundingly high occurrence and demand for swallowing therapy in patients. We were taught about dysphagia, and what it is, some of the techniques that can be used to treat it, and how to assess for swallowing difficulties, but I doubt that we spent more than 5 hours of class learning about it. This is shocking, considering the high incidence of this condition in the real world.

Diagnosing dysphagia has many components that need to be considered, and not all that can be clinically assessed during a bedside evaluation. To give you an idea, I’ll start with the anatomy. When you put food into your mouth, it enters the oral cavity, and is masticated (chewed) and prepared for the swallow by the tongue. This bolus is propelled backwards by the tongue, into the pharynx (throat). Now just below the base of your tongue, you get what we call the valeculi, which is like a little pouch, and the epiglottis, which is a “flap” that drops down to close off your airway when you swallow. Your airway (trachea) sits in front – so when you touch your throat, that bony part that you are touching is your airway. Behind that, between your airway and your spine, sits your esophagus, which carries the food down to your stomach.

  

Often when patients swallow, they cough, which is an indication that some of the food goes into the lungs, which is dangerous. An assessment that we often do to clinically assess whether this aspiration occurs, is called a modified barium swallow study (videoswallow). Doctors are not trained to assess for this, or interpret a swallow study for that matter, so they refer to us to diagnose these patients. Now, you get two types of swallow studies: a barium swallow, which is mainly focused on the movement of the food down the esophagus and into the stomach, to test for reflux. Then you get a videoswallow, which is what we do, and this focuses on the throat and entrance to the lungs, so that we can test the functionality of a swallow, and determine whether patients are able to swallow safely or not.

Here’s a quick swallowing 101 lesson: For a normal and safe swallow to occur, there should be good oral control, tongue movement, bolus propulsion backwards, and there should be no residue on the tongue or anywhere in the throat. Sometimes, some of the food remains in the pharynx, and gets caught in the valleculi and pyriform sinuses, which may eventually overflow into the airway and result in aspiration. This can often be cleared using manoeuvres on how to position your head during swallowing, and other techniques that may help clear the food from these structures. If the food does not clear, it is considered a high risk for aspiration, and the patient is not safe for oral feeding.

So I had a patient who was referred to me following a rather large stroke. I assessed his swallowing, and although he didn’t display any clinical signs of aspiration (such as coughing, throat clearing, wet voice, watering eyes or delayed coughing), my gut instinct told me that this patient is aspirating. So I took him for a videoswallow, and I was right. My patient was aspirating severely on all three consistencies of food (thin fluids, puree such as yoghurt, and solids – a cookie). Not only was he aspirating severely, but the aspiration was silent, which means that the coughing reflex – our airway’s protective mechanism - is not present and there is no clinical sign of aspiration. My recommendation was to have a PEG tube inserted, and that we would commence swallowing therapy in an attempt to rehabilitate his swallow.

Once a month, for three months, I took my patient to X-Rays to repeat the videoswallow to monitor for improvement of his swallowing, and hopefully to slowly get him back onto an oral diet. The risk for aspiration remained high, and I did not feel comfortable allowing my patient any oral intake. So we continued religiously doing the swallowing exercises, and feeding him via the PEG tube. So come month 3, my patient comes back to X-Rays for his follow-up videoswallow. As I walk into radiology, my patient is not there, so I set up and prepare the room, only to get a phone-call from his wife. “Hello Lauren, I am sitting with the report in my hand, and it says that he may eat. Does this mean that the feeding tube can come out?”. Imagine my horror at hearing this result, when I have yet to lay eyes on my patient. Considering his history, I highly doubted that he is able to swallow safely. So I calmly asked them to please return so that I can confirm these results myself.

In the mean time, I flew into the radiologist’s offices, trying very hard to put a smile on my face, demanding to know who performed my videoswallow and what EXACTLY they saw. One very friendly, very flirty and very young doctor was very eager to tell me that he even gave my patient a marshmallow (because yes this definitely replicates the consistency of your meat, hey?) and he was able to swallow it safely. Red in the face, eyes blazing, heart racing, and breathing very heavily, I slapped a smile on my face and asked him to please assist me in repeating the study so that I can confirm the results personally.

My patient arrives, and we proceed into the screening room. I invite his wife in too, so that she can also see the results of the swallow. I give my patient a sip of water… severe pooling in the valleculi, with failure to clear using any of our manoeuvres. This swallow has not started on a good note. Am I now supposed to break his newly heightened spirits by telling him he may not really swallow? Perhaps the other consistencies will get better.

I give him a spoon full of yoghurt, and my heart drops a little more. The pooling in the valleculi hasn’t improved at all, and in fact the yoghurt was completely lining the entrance to the airway. Damn! I don’t even feel safe to give him a cookie - this result is not good at all, but my patient has been told that he may eat, and he is so happy about it, so I ignore the blaring red lights, I dip my cookie in the yoghurt for the contrast to show up, and I ask my patient to chew it and swallow when he is ready. I give him a sip of water hoping that it will wash the residue out of the valleculi and clear the pharynx, maybe this will give me a safe option to send him home with.

I think I stood starring at that screen for at least a minute, trying to figure out how I can gently drag his spirits through the mud. I turn around slowly to look at him, and watch as his face turns from excitement and joy into disappointment and sadness. What did he see on my face? Sadness? Disappointment? Horror? Fear? All the emotions I was feeling. So I slowly start explaining the structures to them, and I replay the video to show them what happened to the bolus, where it lodged in the pharynx, and how I tried to clear it using every possible technique.

Here’s what I saw (please excuse the quality, this was taken off a screen)… The first photo is a clear pharynx before any boluses were presented. The second photo is following the cookie, which you will see is the dark stuff in the throat. (1) tongue, (2) valleculi, (3) epiglottis, (4) entrance to the airway, (5) esophagus.

       

   

My advice to this patient was to only start taking in small bites of food with a puree consistency, and to take a sip of water after each bite. I was not at all happy to send him home like this, but to now take the new privilege of eating away – I just couldn’t.

A month later we repeated the videoswallow, and it looked somewhat better, but still not great. I had learned though, that my patient had decided to start eating normally again, against my recommendation, and was “doing well”. His PEG tube had now become a nuisance and was getting infected. So, against my recommendation that this was not safe, they went to their doctor, who removed the PEG tube, and he has been eating orally since.

Sometimes as Speech Therapists we have to play the bad guy, and refuse to allow the small, pleasurable things in life, such as eating and drinking. It sucks, but it is really in the best interest of the patient. It is not easy to watch a patient’s hopes falter and die down, and try and encourage them in therapy when they are so despondent that they refuse to even look at you. These are the moments in your day that drain you of emotional energy, and wipe that smile off your face. I often walk around with just that, a face that I put on for the sake of my patients. But hey, if it means that I know my patients will be safe, and I will not be the cause of them developing a serious illness, I am happy to play the bad guy.

Until next time…

Xxx

The transition from public to private

(31 March 2018)

I find myself marveling at the difference between the public sector, and private practice. I never imagined myself to have experienced some of the things I have so early on in my career.

Working in a government hospital in South Africa for a year has exposed me to a whole different world. Being fresh out of varsity (well, sort-of), you walk in to your first ever job, and are expected to take the lives of sickly people into your hands and make a confident call regarding their treatment. That is a scary thought. Let me explain…

As a Speech Therapist, part of our scope of practice is working with people who experience swallowing difficulties. That is, a neurological, physiological or muscular problem has occurred, causing a patient to either aspirate (food enters the airway) on their food, or be at high risk for this to happen. In a nutshell, imagine drinking a glass of water, and having some of it go to your lungs. Now this doesn’t only happen on water, but on everything you eat. It will most likely result in the development of pneumonia, or worst case scenario cause a patient to drown on their food.

So nonetheless, I walk into community service, head held high, feeling very important, and trying my absolute best to hide my very intense nerves. Needless to say it took me no longer than two weeks to be humbled and very quickly realize that those nerves were there for a reason. Doctors ask you questions that you (a) don’t understand 80% of, and (b) are expected to be able to answer with accuracy. So you waffle, and talk the biggest load of hogwash, throwing a couple of academic terms in to sound like you know what you are saying. Not even to mention you now have to work with patients who have all kinds of funny illnesses, diseases, psychological imbalances and some very traumatic injuries. To mention a few, I worked with people who were brutally attacked to the verge of death, kidney failure patients, epilepsy patients, babies who were born unable to suck, children with neurological difficulties, autism kiddies, cerebral palsy kids, psychological traumas, stroke patients, and more. Often you will come across a patient by accident, who has been misdiagnosed by the new intern doctor who “forgot” to refer to you. This is government. You don’t wear your nice shoes and good clothes to work, because at the end of the day you walk out feeling a sense of urgency to find a shower, and wonder what will come across your path tomorrow.

I started in private practice in January of this year (2018), and am astounded by the complete change in atmosphere, the respect now shown to you, and the prevalence of dysphagia cases! Suddenly, doctors (well, about 60% of doctors) know what you do, and will refer patients to you. Your requests for feeding tubes are seen to as soon as possible, if not on the same day, and low and behold, your patients understand you!! Coming from a setting in which most of your population is third, fourth or fifth language English speakers, suddenly 90% of your clients are first language speakers, and can communicate with you on a level far beyond any experience you may have gotten. Eeeek!! Now suddenly I have to start sounding like I know what I am talking about, and actually making sense too. I have now been working in private for a total of three months, and already I have learned more than what I learned in community service and university combined. Okay, perhaps varsity laid out the groundwork for me, but the extent to which application of knowledge is actually used is astronomical. You dig so deep, and come up with these seemingly far-fetched conclusions that really actually make sense, and earn a high level of respect from the doctors and the allied community. Critical in-patients need to be seen daily, and bi-weekly or weekly for out-patients, where in the past many were only seen once a month.

You often come across people who say they hate their jobs, and that work will always be work. I am one of the lucky few who can honestly say that I love my job. Yes sure, I very often feel like I am drowning, turn into a stress-ball, and wish that I could finish work earlier, or have a day off here and there, but on the whole, my job never ceases to amaze me. Not a day goes by that something interesting doesn’t happen; sometimes patients will say things that have you balling with laughter, you will make someone’s day by telling them their PEG tube can be removed, you will get a smile from that very sick ICU patient who can hardly function, or you will be called a “rude pig” by your delusional patient for not giving them a sip of water.

Although the nature of many of the cases we come across in public and private is the same, there is a certain level of care demanded from you in private that you won’t find in government. You are now able to communicate with patients on a high level, you are taken seriously by your colleagues and other professionals, and your job suddenly becomes important. Hospitals now become your home. Medicine fascinates you, and you are no longer that afraid of needles (hmmmm, yes okay that is debatable, but you do become accustomed to the necessity thereof, and won’t fight against it anymore). The transition from public to private was daunting, and took some time, but man oh man has it been a fun journey.

Later…

Xxx