February is American Heart Health month, so we thought it would be a great opportunity to connect with our friend and course instructor, Beth Cormell, M.S., CCC-SLP to find out what it is like to work as a Speech-Language Pathologist in an Acute Care Heart and Vascular department.
7:30 am: Starting the Day
It’s the first day of the work week for me and I knew it was going to be a great day. All the signs pointed to it. I was on time, found a good parking spot, someone held the hospital door for me, and the elevator door immediately opened!
My usual morning routine is to grab my Vocera communication device, print my list for the day, and check my email. The speech team is starting the day with 69 patients on caseload with four speech pathologists working. Ten patients are assigned to me with one FEES (Fiberoptic Endoscopic Evaluation of Swallowing), one MBSS (Modified Barium Swallow Study), four new evaluations, and the remaining patients are for follow-ups or treatments. Since I cover the heart and vascular hospital, my caseload primarily consists of patients with heart failure, cardiac arrest, and heart surgeries. Five of the ten patients are on airborne, contact, and or droplet precautions. Welcome to the hospital in winter!
The first tasks are to complete the chart review and schedule that MBSS. The patient had a tracheostomy tube, was non-English speaking, and had a history of esophageal cancer, as well as bilateral true vocal fold (TVF) paralysis in the adducted position. Completing the chart review and scheduling the MBSS with the interpreter took approximately thirty minutes. Fingers crossed I can stay on top of my productivity requirements for the day! Luckily, the interpreter was on time and ready and the study went smoothly. I looked at the clock and another 50 minutes had just evaporated, and I still have not completed the report or contacted the medical team with the results of this study, so I’d better keep moving!
Next up is a young man who experienced cardiac arrest and pancreatitis. He had been down for 20 minutes and intubated for two days before self-extubating. Of course, he was hungry, and his mom was frantic for him to eat and drink. The CICU nurses pleaded for an immediate evaluation, and I was happy to oblige. Despite reports of being combative with the night staff, he was happy to participate in the clinical swallow exam and exhibited no clinical signs of aspiration. We recommended initiating clear liquids due to the pancreatitis and he was overjoyed! The cognitive evaluation would have to wait until his labs improved and I had more time.
The next stop is to check on a middle-aged woman who had a history of congestive heart failure (CHF), two cerebrovascular accidents (CVAs), and a recent percutaneous endoscopic gastronomy (PEG) placement. She remains intubated, so I met with the nurse to discuss spontaneous breathing and awakening trials. She required some sedation to keep her calm while on the ventilator, yet she was awake with her eyes open. At this point, she was emotionally labile and did not follow commands. I was hoping she would be a candidate for the early progressive mobility program with a focus on cognitive and communication functions. She isn’t quite ready today, but I will keep checking back.
On to the next new consult, a patient with CHF, chronic obstructive pulmonary disease (COPD) and flu. He was admitted to the CICU with sepsis requiring BiPAP (bilevel positive airway pressure). As I was walking in to see the patient, the Respiratory Therapist snuck in front of me to provide a breathing treatment. Since BiPAP was off, I took the opportunity to assess his swallowing. Based on the results of the clinical assessment, he was cleared for sips of water and meds by mouth. I will be back tomorrow to reassess. If his respiratory status continues to improve, I’m optimistic that he will be ready to eat breakfast.
It’s still morning! Time for a quick coffee break, as there are a few more things to do before lunch. A code blue was called in dialysis and unfortunately, this was for a patient that I was supposed to evaluate. She will not need my services today, yet she is well-known to our department, and I’ll be checking in on her in a day or two.
On to an escalated treatment. This patient was recently evaluated by speech pathology, and he was recommended to consume a regular diet. Unfortunately, he had a recent decline, a severe leg infection, and had to have an above-the-knee amputation (AKA). Since the surgery, the nurses have reported concern for aspiration with medications and meals were being held. Upon my reassessment, he was lethargic and appeared to be aspirating liquids. I recommended NPO except for meds crushed in applesauce. Palliative care was consulted to determine the patient’s goals of care, as he appeared to be reaching the end of his life. I will follow up again after the palliative care consultation.
12:30 Lunch Time
Finally, some lunch at my desk while completing chart reviews for the afternoon. Of course, I also squeezed in a few laughs with my awesome co-workers.
Next, I completed a FEES for a patient who was admitted with an intracranial hemorrhage (ICH) requiring a craniotomy and a post-operative tracheostomy. This case required coordination of staff: scheduling an interpreter, a nurse, and a rehab technician. The FEES revealed aspiration of secretions and aspiration of food/drinks. The good news is, I was able to establish a treatment plan. It will be a long battle, but I am hopeful for this patient’s recovery.
My next patient is a very elderly woman with COVID. She was referred with complaints of food sticking and inability to take anything but sips of liquid. Her complaints were consistent with likely esophageal dysphagia, so I recommended a barium swallow study (BASW) and recommended full liquids in the interim. I will follow up tomorrow to review the results with her.
My last patient of the day is an elderly gentleman recovering from a (coronary artery bypass graft) CABG with ICU delirium. His mentation was beginning to clear, and he did not show clinical signs of aspiration. I recommended full liquids for the night and reassessment in the morning.
5:45 pm Wrap Up and Head Home
All throughout the day there are constant interruptions. There are texts for communication within the speech pathology department and with other medical providers. Don’t forget all the beeps and bells of all the monitoring devices and codes being called. I do love my job, but by the end of the day, I look forward to a little peace and quiet at home. It’s been a long day on my feet, but I remind myself that I went into this profession to help people. SLPs have the privilege of working with patients with dysphagia. Swallowing is so much more than nourishing the body, it’s socialization, pleasure, and love.
Now it’s time to go home and nourish myself and my family. Tomorrow will be another day of collaboration, learning, helping, and a little bit of chaos. One thing I can say for certain is that it’s never boring!
Thank you, Beth, for taking the time to share your day with us.
Beth Cormell, M.S., CCC-SLP works at Rex UNC’s Heart and Vascular Hospital. Beth also teaches webinars and FEES Training courses for Carolina Speech Pathology: A Patheous Health Imaging Company.
