Hierarchy of Cues and Verbal Feedback

In general, during a confrontational naming task, cues are as follows:

1. Extra time (about 15 seconds)
   
2. Function, location, property cues (i.e. semantic feature analysis)
   
3. Cloze condition cueing such as "You sleep in a _________."
4. Initial letter cue or
   
5. Phonemic cue

Verbal feedback should consist of:

"That's right." or "That's correct."
"That's wrong." or "That's not correct."

Additionally, verbal feedback can provide the person with information about what he or she is doing correctly, such as: "That's right. You allowed yourself extra time to think before you answered."

Or, conversely, what he or she is doing incorrectly, as in: "That's not correct. Try to wait before you answer. Give yourself extra time to find the word."

Coma Arousal

If you are inclined, consider bringing in items to use in coma arousal/stimulation. Please don't purchase anything. Just look around, see what you already have that might be appropriate...

Patient Care Team Conference

During team conference, think in terms of "bullets" of information.
Keep your statements short, precise.
Avoid emotionalism, if possible.
Stay objective.

Advice for all of us!

Monday September 24th

Update: Practicum canceled for today.

Trach Inservice Postponed

Trach inservice has been postponed...

Page me in the morning, and I will let you know what is happening...

Thank you.

Coma Stimulation Part II

Coma arousal therapy should begin as soon as possible or when the patient is medically stable. The brain must receive frequent and intense repetitions of the stimulus items to be stimulated. Administration can vary from 1-8 hours/day, depending upon each individual. Listed below are the sensory modalities to treat and suggestions for different stimulus items.

AREAS TO TREAT
Sensory Modalities	Stimulus Items
Auditory	banging items together ring bells music loud whistle familiar voices of family/friends telephone ringing knock on door call person's name general conversation with patient television/radio
Tactile	temperatures (warm/cool) touch (different fabrics such as fur, silk, feathers, corduroy) pressure (deep pressure massage) vibrator
Visual	pictures of favorite people, pets, or items bright colors moving objects, flashcards (different shapes/colors)
Olfactory	familiar fragrance citrus coffee flowers peppermint spices eucalyptus oils garlic
Taste	swabs (peppermint, lemon) squeeze lemon juice on tongue mustard salt soy sauce sugar sucker
Proprioception	range of motion exercises (roll side to side) alternating movements (arms/legs raised)

Patient Interview Comment

Coma Stimulation

What do you know about coma stimulation?

What kind of stimulation?
Is it effective?
Who does it?
What is the rationale?
For how long?

What is a persistent vegetative state?

Cues and Timing

Timing of cues is important. Of value is allowing time for the person to process the task; however, too much latency between the stimulus presentation and the person's first response can lead to even greater failure.

So, do allow approximately 15 seconds for a response. If 15 seconds goes by and you have not elicited any kind of verbal or gestural response, then give a cue or prompt.

Allow approximately 10 to 15 seconds to check effectiveness of the cue, then give the next type of cue.

If this final cue does not work, then model the target response.

Give verbal feedback for each response you elicit.

Swallowing Dysfunction and TEE

Authors Full NameKohr, Lisa M. Dargan, Margaret. Hague, Amy. Nelson, Suzanne P. Duffy, Elise. Backer, Carl L. Mavroudis, Constantine.
InstitutionDivision of Cardiovascular-Thoracic Surgery, Department of Speech and Language Pathology, Children's Memoiral Hospital,
TitleThe incidence of dysphagia in pediatric patients after open heart procedures with transesophageal echocardiography.
SourceAnnals of Thoracic Surgery. 76(5):1450-6, 2003 Nov.

AbstractBACKGROUND: Pediatric patients who undergo open heart operations may be at risk for the development of dysphagia because of interventions such as intubation and transesophageal echocardiography. Although the occurrence of dysphagia after cardiac surgical procedures in adults is reported to be 3% to 4%, the incidence in children and adolescents has not been documented. This study was undertaken to determine the incidence of and risk factors contributing to dysphagia in pediatric patients after open heart procedures. METHODS: Fifty patients were evaluated after open heart operations with transesophageal echocardiography between March 1, 1999, and September 30, 1999. The diagnosis of dysphagia was made by a speech pathologist using a clinical swallowing evaluation. Potential predictors examined included demographic variables, anatomical diagnosis, surgical procedure, size of the transesophageal echocardiographic probe in relation to body size, length of probe insertion time, preoperative patient acuity status, duration of intubation, and time until discharge. RESULTS: Dysphagia was found in 9 (18%) of the 50 patients. Risk factors identified were age of less than 3 years (odds ratio, 20.4; 95% confidence interval, 2.7 to 157; p = 0.002), intubation prior to operation (odds ratio, 17.7; 95% confidence interval, 9.4 to 210; p = 0.004), intubation for more than 7 days (odds ratio, 74.7; 95% confidence interval, 13.8 to 405; p = 0.001), and operation for left-sided obstructive lesions (odds ratio, 1.9; 95% confidence interval, 2.2 to 8.3; p = 0.038). The size of the transesophageal echocardiographic probe in relation to the weight of the patient was found to be predictive (p = 0.0001) of dysphagia. Vocal cord paralysis was noted in 4 (8%) of the 50 patients postoperatively. Adverse events related to aspiration occurred in 2 patients (4%). At discharge, nasogastric tube feedings were required in 6 patients (12%), and thickened feedings were recommended for 3 (6%) of the 50 patients. Resolution of dysphagia ranged from 13 to 150 days. CONCLUSIONS: Eighteen percent of patients had dysphagia after an open heart operation with transesophageal echocardiography. Age of less than 3 years, preoperative patient acuity status, longer intubation times, and operation for left-sided obstructions are risk factors for dysphagia in this cohort of pediatric patients. The size of the transesophageal echocardiography probe in relation to the patient's weight was predictive of dysphagia. Physicians should consider using the new mini-multiplane transesophageal echocardiographic probes in patients weighing less than 5.5 kg. Vigilance in monitoring for the signs of preoperative and postoperative dysphagia with prompt referral to a speech therapist can substantially reduce patient morbidity, length of hospital stay, and requirement of prolonged nasogastric tube use.

AuthorsRousou JA. Tighe DA. Garb JL. Krasner H. Engelman RM. Flack JE 3rd. Deaton DW.
Authors Full NameRousou, J A. Tighe, D A. Garb, J L. Krasner, H. Engelman, R M. Flack, J E 3rd. Deaton, D W.
InstitutionDepartment of Anesthesiology, Baystate Medical Center, Springfield, Massachusetts 01107, USA.
TitleRisk of dysphagia after transesophageal echocardiography during cardiac operations.
SourceAnnals of Thoracic Surgery. 69(2):486-9; discussion 489-90, 2000 Feb.
Local MessagesMUSC Library has journal title; click Library Holdings link for issues.
AbstractBACKGROUND: Dysphagia can be a significant complication following cardiac operations. This study evaluates its incidence and relationship to intraoperative transesophageal echocardiography (TEE) for specific indications versus known factors such as stroke or prolonged intubation. METHODS: Records of 838 consecutive cardiac surgical patients were reviewed, and categorized into those who received TEE for specific indications versus those who did not (nonTEE). Dysphagia was recorded when symptoms were confirmed by barium cineradiography. Multiple logistic regression identified significant factors causing dysphagia. RESULTS: TEE was significantly related to the development of postoperative dysphagia by multiple logistic regression (p <> CONCLUSIONS: TEE may be an independent risk factor for dysphagia following cardiac operations.

AuthorsHogue CW Jr. Lappas GD. Creswell LL. Ferguson TB Jr. Sample M. Pugh D. Balfe D. Cox JL. Lappas DG.
Authors Full NameHogue, C W Jr. Lappas, G D. Creswell, L L. Ferguson, T B Jr. Sample, M. Pugh, D. Balfe, D. Cox, J L. Lappas, D G.
InstitutionDepartment of Radiology, Washington University School of Medicine, St. Louis, Mo., USA.
TitleSwallowing dysfunction after cardiac operations. Associated adverse outcomes and risk factors including intraoperative transesophageal echocardiography.
SourceJournal of Thoracic & Cardiovascular Surgery. 110(2):517-22, 1995 Aug.
Local MessagesMUSC Library has journal title; click Library Holdings link for issues.
AbstractThe frequency, importance to patient outcomes, and independent predictors of postoperative swallowing dysfunction documented by barium cineradiography were examined in 869 patients undergoing cardiac operations over a 12-month period. Swallowing dysfunction was diagnosed in 34 patients (4% incidence) and was associated with documented pulmonary aspiration in 90% of these patients, increased frequency of pneumonia (p < p =" 0.0002)," p =" 0.0001)," p =" 0.0001)." p =" 0.001)," class="bibrecord-highlight">transesophageal echocardiography (p = 0.003). Dysfunctional swallowing after cardiac operations, a serious complication significantly related to postoperative respiratory morbidity and extended length of hospitalization, is more common in older patients. An association between intraoperative use of transesophageal echocardiography and swallowing dysfunction was also observed in our patients.

At TCU on Thursday the 13th

Just a heads-up: On Thursday, we will be treating our patients on TCU. Think about some of the patients you know, and decide who you'd like to treat vs. who you'd prefer to observe.

T.E.E.

Transesophageal Echocardiogram What is a Transesophageal Echocardiogram? A transesophageal echocardiogram is a special ultrasound test that uses sound waves to take pictures of the heart. This type of echo can take clearer pictures of the heart than regular ultrasound especially in older children and adults. It is also used during heart operations to help guide the surgeon. There is no known risk from ultrasound exposure and no radiation exposure is involved. How is it done? The study is done by passing a special tube down the throat into the esophagus or food pipe. The end of this tube is placed near the heart which allows very clear, detailed pictures to be taken. So, can you think of any reason this procedure might lead to swallowing dysfunction?

Remember that Old Adage...

Remember that old adage "you can't please all of the people all of the time..."? Who is ultimately responsible for decisions made regarding the care of a patient? That is the question of the evening.

Is it the patient?
The patient's nurse?
The attending physician?
The surgeon?
The registered dietician?
The speech pathologist?
The physical or occupational therapists?
The medical student? or the physician's assistant?

Or, is it the team? And who is on that team? Is there a leader of that team? And who is that leader?

The patient?
The doctor?

Ultimately someone has to make the final decisions. How does that person make the right decision given a variety of recommendations? Do a JPEG. Don't do a JPEG. Downsize a trach. Don't downsize a trach. How does that person know that the entire team will agree or disagree? Does that person have the time needed to find out? Why? or why not?

Does it do any good to entrust to someone else communication of your recommendations and your rationale for them? And, are your recommendations always to be followed? Or, are they just recommendations?

And, is your recommendation the same as an "order?" Would suggestion be a more appropriate term? Why? Why not? If so, always or only sometimes?

And, why would someone ever say that a nurse does not "have the whole picture" of her/his patient? Why would someone ever imply that an attending physician did not have "time to know patients" entrusted to him or her?

These are my probing questions this evening. Aspects of being a therapist to consider and reflect upon.

Verbal Feedback

During treatment (not evaluation), verbal feedback of some kind needs to come after each response elicited.

This verbal feedback can be "that's right" vs. "that's wrong" or "that's not right" followed by a cue of some sort. Most semantic cues can be drawn from semantic feature analysis with questions such as:

"where is this found?"
"what do you do with this?"
"what does this item do?"
"to which group does this item belong"
"what does this look like, feel like, taste like, smell like...etc?"

If the question does not elicit a correct response, then providing the information in statement form, such as "you use this to open cans" may assist the person. If not, the first letter of the target word sometimes triggers word retrieval. Finally, the phonemic cue may be given. Often it helps to remind the person to attend to your face with "watch me, listen to me, do what I do."

The verbal feedback that you gave today re: sustaining attention via eye contact, etc. was very appropriate.

Keep up the good work.

Time Zone

Time stamps should be correct now. The time zone was set at "Pacific."

Good News!

Found my misplaced bag on TCU...

Comments

Don't forget: You may find it easier to answer my questions via "comments." This way, we won't forget to discuss these during the practicum. Thanks!

ALS Clinic

I recommend you page me on Friday morning to check my schedule as I am not certain when I am going to be at ALS Clinic.

Thought Organization

What is thought organization anyway? What's semantic feature analysis?

Look It Up

What is an empyema? Can you think of any impact this condition might have for speech pathology?