There is no changing an already made-up mind

9 November 2017

So I have a patient, he is a very sweet little boy (Ben) with a rather sad background. He is 4 years old, and lives with his grandparents and brother. His mom is still in the picture, and spends time with him once every two weeks, or something crazy like that. They came for therapy the other day, and Ben’s granny was telling me about recent developments in this child’s life.

As a young boy, Ben grew up almost in the shadow of his older brother. His father had developed a bond with his brother, that was not carried over to Ben. He would praise his brother, buy him stuff, they would do things together, and none of this would ever happen with Ben. Ben would be pushed around, his father would physically hurt him if he did the smallest thing wrong, and would tell him that he is worthless and should never have been born. His mother, it seems, was a drug addict, and also did not pay much attention to the children and how they were being treated. Long story short, granny saw what was happening, and had a social worker take the kids away from their parents, to now live with their grandparents. Since then, their father has disappeared, and is nowhere to be found, and their mother is now rehabilitating herself, and is doing everything in her power to be a good mother and be a part of their lives.

When Ben first arrived by me, he was extremely shy, did not want to participate, and appeared almost afraid of disobeying his grandmother. I would ask him questions, and his granny would repeat the questions and tell him, rather sternly, to answer. But, we slowly made it through the assessment, and Ben started trusting me and opening up to me more and more. He makes eye contact, does not avoid physical touch, and follows instructions as any 4 year old child would. He enjoys colouring in, and is eager to learn and absorb more information. Ben is a clever little boy, and does well with most activities presented to him.

In my professional opinion, I believe that Ben is neurologically and physiologically fine. I do, however, believe that his personal history with his parents has left some psychological and emotional damage, and that this is what is causing his difficulties in expressing himself, and to a certain extent, hampers his learning. I am not sure whether he has ever been seen by a psychologist, but I do believe that his difficulties are stemming from his emotional and psychological trauma as a young boy.

Ben’s granny one day asked me whether I could book him an appointment with the paediatric neurologist, because she believes that he is Autistic. She has done a lot of reading up on Autism, and the more she reads, the more she is able to identify behaviours in Ben that are indicative of Autism. At the time, I did not agree with her deductions per se, because from what I had seen, there is not much that would indicate Autism. Sure, Ben fixates on the number 13 when we are doing numbers, but other than that there is not much more. He tends to isolate himself from other friends, assumingly for fear of rejection, his emotional past, and he demonstrates difficulty with production of various speech sounds (which has been identified as the result of recurrent ear infection).

Once Ben had been to the paediatric neurologist, his granny came back to me and told me that they say they do not have a diagnosis for him. The wording they used in their letter to me was “Dear Lauren, thank you for your referral of Ben to paeds neuro. Ben is developing well, and shows great improvement from Speech Therapy. Please continue your exceptional work with him”. In other words, no diagnosis. His granny was rather distraught by this result, because she firmly believes that he has got Autism. She then starts telling me about a series she is watching, called “Atypical”, about a boy who has Autism, who is in high school and is trying to find love. She says to me that all the behaviours he demonstrates are what she sees in Ben, and she is sure he has Autism.

I am currently busy watching the series, and no doubt that the behaviours that the actor demonstrates are those of an individual with Autism, but I can honestly say that I do not agree with his grandmother. I do not believe that Ben has Autism, I do believe that his background has the biggest role to play in his current functional abilities. I also find it rather sad that his grandmother, who spends most of her time with him, is looking for a label to pin to her boy, so that she can blame it on that. I will never tell her she is wrong, because as a professional I can only tell patients what my recommendation would be, and perhaps refer them to a psychologist, but it breaks my heart that the only way around this for her is to label this poor boy something that he is not.

Until later…

Xoxo

The feeling of making a difference...

(29 June 2017)

The feeling of making a difference…

Two years later and the inspiration hits me once more… I am currently a community service Speech-Language Pathologist at a public hospital in Pretoria, South Africa. Since I last wrote, I completed my honors degree, obtained my Masters degree, and have now been working for six months.

So I get to work on Monday feeling tired and demotivated after a busy weekend. I’m going through the motions for the day, running around like a mad thing with all the patients, because my colleague is on leave. After lunch I finally manage to go to the wards. So because the hospital that I work in is small, our wards are combined medical and psychiatric patients. Up I go to ward five (the male ward), and I have got two referrals, one of which is a TBI (traumatic brain injury). So I go to the patient, glance at him (he doesn’t look good) and start off by reading the file.

So Mr X’s name in the file is “Delta Unknown”, he was admitted to the hospital over the weekend – down-referred form a tertiary hospital’s neuro ward because they needed the bed. Mr X was assaulted and admitted to hospital on the 3^rd of March 2017, where he has been diagnosed with severe TBI and dehydration. They still do not know his name, and state that he cannot communicate. Every now and then Mr X would make this moaning noise, almost a cry, for a reason not apparent to me.

So I approach the patient with hopes not being too high, and a slight sinking feeling in my stomach because I expect the prognosis to be poor… The patient is lying on his back, in a position that is similar to a foetal position in an infant, in a nappy, and my goodness is he skinny. His thighs the size of my forearm. I approach him while putting my gloves on and try and wake him up. The patient is looking at the roof with an expression of non-recognition, suggesting visual difficulties. As I start talking, he makes that moaning noise again, and my hopes drop just a little bit more… This patient isn’t all that aware of what his circumstances are, or what has happened. Before I finish, I quickly had to do a basic swallow assessment on this patient. So I bring the glass of water closer to his mouth, and he purses his lips as though he knows that is going to happen (interesting). So I give him a sip of water, and feel a safe, strong swallow, when through clenched teeth and in a whisper, says to me “more please”. Just to confirm that I heard him correctly, I ask him “sir would you like some more water”, and he answers “yes please”. Through small sips of water, and very basic questions, I managed to find out Mr X’s name, his age, and where he is from before he became upset and distraught again.

I told the nurses how I managed to get this information out of him, so when I arrived at work the next day, during meal times one nurse had managed to obtain a contact number and get hold of his family. What an amazing development! And this because I managed to figure out that this patient is somewhat aware of his surroundings, and is able to communicate. I walked into Mr X’s hospital room the following day, to find his family crowded around him crying. His father, an elderly man, looked up at me and said “thank you”. I have never before been speechless in front of one of my patients, but that day I was unable to say a word, and had tears streaming down my face as I watched them reunite with their son (who they believed had been dead for the last 4 months).

Where we stand today (November 2017), almost 5 months later, I have just discharged Mr X from Speech Therapy. He has gained weight, he is feeding well, and has developed into a witty young man with a good sense of humour. Mr X now loves with his three lovely sisters, and although he is still wheelchair bound and completely reliant on others to get him from one place to the next, intends on studying mechanical engineering in 2018.

Being a Speech Therapist, especially in the public sector, it becomes somewhat of a necessity to develop a certain ‘hardness’ towards your patients. We see some very upsetting cases, people who have been brutally beaten, or who have some serious neurological deficits, and yet we still need to hold our heads up high and put a smile on our faces every day. We need to learn how to be stern to those patients who are refusing therapy, and we need to make the call on how a patient will be able to feed whether they are fully functional or not. There is a lot that falls on us as therapists, and a lot more than what the medical community believes. We are the invisible healers…

Watch this space for more stories and insight into the life of a new Speech Therapist…

Xoxo

Follow-up on my patient with Wernicke's Aphasia

Finally I get a chance to write a post again. Being a 4th year student isn't easy, and I'm not touching base.

As I have explained in previous posts, Aphasia is a complex disorder, that can present itself in many ways. The two main types you get are expressive Aphasia, where the main problem is word-finding problems, and a receptive Aphasia, where you don't understand what people around you are saying.

You have probably met my patient in my blog "My first experience of a truly helpless feeling". She is an African lady who had a stroke some 10 weeks ago, and was diagnosed with Wernicke's Aphasia, with an Apraxic component. She speaks mostly jargon, and words that don't exist, and doesn't understand when people speak to her.

In my previous blog, approximately 3 weeks ago, this patient didn't understand what is going on around her. She would respond to you with prolonged sounds and utterances that don't make any sense, and wasn't aware that no one understood when she spoke. 

In the mean time, this patient has progressed in various aspects. She does still not understand when you speak to her, but she understands when you show her what you want her to do. If you give her mixed pictures of wild animals and pets, or fruit and vegetables, she is fully capable of putting them under their correct headings. She is able to differentiate between two objects when you ask her to give you one, and she can walk on her own.
Now and then, there are some automatic responses that come through with her speech, which lead you to believe that she understands what you are saying. For example, she will greet you appropriately when you walk into her room, she nods her head when you ask her something, and she says "I'm fine" when you ask how she is. I also got a "No don't raise it" from her one day when I wanted to raise the side bar on her bed.

In my previous post I mentioned that this patient has difficulty swallowing, due to her lack of being able to plan the movements for swallowing. At that time, they had just inserted a naso-gastric tube to feed her. About a week later they inserted a PEG tube, which is a more permanent option. A PEG tube is one that is inserted through the abdomen wall, directly into the stomach. Patients with PEG tubes do get hungry, but they eat liquid supplements. I have spoken to patients that say they sometimes get cravings for the taste of various foods (coffee and cheese burgers), but they don't crave it like we do.

At varsity, they never teach you how to feed a patient that aspirates on their food, because it is one of the most dangerous things you can do. So at the hospital, we are expected to be able to do this. As you can imagine my nerves went haywire, because I can kill the patient like that. So I tried, and I got it right, but every time the patient coughs I jump 10 feet high like a scared moegoe, and run for tissues and a bucket.

This week that just passed, the therapists told me I am doing very well, and that I should now see Mrs X on my own (something of which I am very proud). I do therapy with mostly liquids, because this is the safest option. I vary between water, tea and yoghurt. Water is the safest, because your body produces water, and it won't do much harm if it gets into the lungs. Tea I use because it has a taste to it, and it is hot, which will stimulate the nerves and hopefully initiate a swallow. And yoghurt I have just about given up on trying.

I use a teaspoon and put a little bit in the patient's mouth. She Opens and closes her mouth, but then holds the liquid in her mouth. You can see that she knows she is supposed to swallow, but she doesn't know how. And the more she thinks about it, the less she gets it right. She has even gotten to the point where she tilts her head backward to get the liquid into her throat to swallow it.

In the beginning of each session I am usually able to elicit one or two swallows, because her mind is not on what she is doing. I walk in and shove the cup of tea into her hand so that she can take a sip (which she can do - it's an automatic response), and then I usually get a swallow. She then realizes that she is supposed to be swallowing, and forgets completely how. I have tried distracting her by getting her to focus on another activity, like matching objects and pictures, categorization, etc, which works now and then, but sometimes she forgets completely that there is something in her mouth and tries talking. Not good.

This patient has been in hospital now for about 10 weeks, and is about to go home. She has started realizing that no one understands when she speaks, so she speaks a lot less than when I saw her the first time. She knows that she can't get her body to do what her mind is telling it to, and has started becoming depressed. She will be discharged to a Rehab soon, so I'm hoping they will be able to get somewhere with her Apraxia. It's going to be a long journey.


Xxx

My first experience of a truely helpless feeling

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