Clinical Swallow Evaluation - our skills are golden
Updated: Jun 10, 2020
As we approach the height of summer we let out the smallest sigh of relief as some of the tight restrictions we have been working with are very slowly and cautiously being lifted. This feeling is slightly tinged with the realisation that many constraints to usual practice, that we have been living with for the last three months, will remain in place for the foreseeable future, and so we prepare ourselves for what is being termed ‘the new normal’.
During the last few weeks we have demonstrated our profession’s adaptability and readiness to learn new skills, so we can do the best for our patients with speech voice and swallowing problems. For the dysphagia specialist speech and language therapist the challenge has been to continue to support existing patients whilst dealing with this wave of new referrals related to COVID19.
Staff on the IT helpdesk have become our new best friends, assisting us to put systems in place to enable us to provide remote services. We’ve learned from the experience of our antipodean colleagues (Ward et al) and the virtual dysphagia assessment has been described (Soldatova et al).
Whilst reduced access to instrumental swallow evaluation will continue to frustrate us, we hope that the conversation we had with Dr Paula Leslie and Professor Stephen McHanwell will remind you that when assessing patients with complex eating and drinking problems our core skills - dysphagia and beyond - are GOLDEN. At a time when it can be tempting to be drawn into all the things we can’t do, the conversation will remind you of all the skills and knowledge that you can, and do, bring to the task of assessing swallow function.
More than ever before we can draw on the full range of opportunities in assessing the patient’s function. In our last blog and PodChat Dr Jackie McRae described how delivering mouth-care enabled her to anticipate problems with speech, swallow and respiratory function. Even if we are only able to observe the patient from the other side of a glass door there is a wealth of information that we can glean. The patient’s level of consciousness, ability to communicate, and posture. A thorough check of the medical and social history prepares us for what we might find and highlights any risk factors. Talking to staff or relatives gives us an idea of that patient’s cognition and problems, and their preferences.
If we’re able to enter and get close enough to engage with the patient we are assessing a number of things - communication, speech and voice quality, cranial nerve weakness, oral hygiene. All of this before we have reached for a torch or spoon.
The work we do even before we enter the ward enables us to be fully prepared and alert to the information we are planning to learn; this is not just about whether the patient aspirates or not. Use of assessment protocols help us to be thorough but we must remain flexible and be prepared to be inventive and resourceful.
Doing the best assessment we can will ensure that, alongside the multidisciplinary team and the patient’s family, we can plan for the patient and optimise safe care, nutrition and rehabilitation.
The impact of COVID19 on the sense of taste and smell is now well documented and we must be mindful of how this may be impacting on appetite and willingness to swallow. Learning the patient’s preferences ensures that any bolus trails are meaningful and will elicit the strongest response.Paula reminds us that eating and drinking is a sensory and motor act and we must not forget the importance of preparation for eating – aroma, sounds of food being prepared, the sight of something looking appetising. Challenging on a ward but Maggie Lee Huckabee talks of using black pepper essential oil with patients to stimulate a desire to swallow.
No other profession has our knowledge of the complex swallow mechanism but if that knowledge needs a bit of dusting off then you will enjoy Professor McHanwell’s wonderful description of the muscles and cranial nerves involved in the act of swallowing. The oro-motor and cranial nerve exam is a vital part of the clinical swallow exam but if we are using videoconferencing it will only be a partial exam. However, this still gives us invaluable information for predicting and understanding the swallow problem and directing our management strategies, compensation and rehabilitation.
This podcast with Dr Paula Leslie and Professor Stephen McHanwell is an episode to cherish as a refresher of the skills and knowledge you already have. Feel confident in your “unconscious competence” and do share with your colleagues and anyone new to dysphagia as an educational piece. Enjoy!
Impact of dysphagia severity on clinical decision making via telerehabilitation. Ward EC, Burns CL, Theodoros DG, Russell TG. J E Health. 2014;20(4):296-303.
Virtual Dysphagia Evaluation: Practical Guidelines for Dysphagia Management in the Context of the COVID-19 Pandemic. Soldatova L, et. al. 2020 Otolaryngology–Head and Neck Surgery. 1–4
Dysphagia Following Stroke. Third Edition Daniels SK, Huckabee M, Godzikowska K 2019 Plural Publishing
Go to our resources page for companion notes to the podcast.
Biography: Professor Stephen McHanwell
Emeritus Professor Stephen McHanwell has recently retired from Newcastle University where he was Professor of Anatomical Sciences in the School of Medical Education. He is a National Teaching Fellow. He has been involved in Speech and Language Therapy education for over 30 years including the teaching of the anatomy of speech and language to undergraduate and postgraduate students taking courses in Newcastle. His main academic research interests, working with colleagues in Complutense University in Madrid, are in the anatomy and physiology of the larynx. He is co-author, with Professor Martin Atkinson of Basic Medical Science for Speech and Language Therapy Students recently published in its second edition by J&R Press in 2018.
Martin Atkinson and Stephen McHanwell (2018). Basic Medical Science for Speech and Language Therapy Students 2nd Ed. Guilford, Surrey: J&R Press (www.jr-press.co.uk) ISBN 978-1-907826-23-8
Biography: Dr Paula Leslie
Dr Paula Leslie maintains full clinical speech and language therapy (pathology) licenses in the USA (CCC-SLP) and UK (FRCSLT) where she is a Specialist Advisor to the Royal College of Speech and Language Therapists in swallowing disorders. Paula started out as a speech and language therapist wanting to work only with adults who stammer, worked in almost every area of speech and language therapy in the NHS, and ended up specializing in decision making and ethics. A stint as a research assistant in stroke issues, led to collaborations, programme design, a decade abroad, and a degree in bioethics.
Her interests include the process of clinical decision making, health professionals’ education and non-traditional routes to advanced clinical training. She publishes, provides support to researchers, and provides continuing education from grassroots to international level and across the health professions on complex clinical decision making, ethics and end of life decisions in vulnerable populations. From this work came the idea for a little book to help those on the front-line and their students:
Leslie, P & Crawford, H. (2017). The Concise Guide to Decision Making and Ethics in Dysphagia. Guildford: J&R Press Ltd.