Morning guys. I'm Siobhan, a second year medical resident. Last night
I admitted a patient with a new stroke to the hospital.
I've just seen a patient in the emergency department who's presenting with a stroke.
This is a woman in her 70's, who came in with a left facial droop and her speech is a little bit slurred as well.
Unfortunately, these symptoms started about 24 hours ago and she just came to the emergency department now.
So there's not much we can do to reverse it,
but instead we're going to work to improve her symptoms and prevent a future stroke.
So I'm going to admit her to the hospital now. I'm interested to see how she's actually doing today.
I'll be meeting with the speech and language
pathologist as well as the dietician to see if she's able to swallow properly or if the stroke has had a big impact on it.
Hey Christina.
Oh hey Siobhan. Good morning. Hi. How are you doing? I'm good, thanks. How are you? Good.
So I was wondering if you had a chance to
hear about the the patient with the right mca stroke, who came in last night. I did, yes.
Yeah, I actually got a referral for her this morning. Oh okay, amazing.
So I wanted to... I'm hoping that you'd be able to see her early on, just because I've left her NPO for now.
And I was actually wondering maybe I could be a part or like see the assessment on how it's done. Sure!
Why don't you just tell us a little bit about what is an SLP? Yeah, so an SLP stands for speech-language
pathologist. So we are experts in communication,
feeding and swallowing.
And what we can do is we look at so many different
aspects from even from babies all the way up to adults of any age really.
Yeah, so some of the things we do can be helping people with their speech.
So all the sounds they made when they're speaking and how they're articulating their language,
so how they understand and how they express themselves. In acute care medicine they look swallowing or dysphasia, which is the medical term for
difficulty or disorder of swallowing, is
primarily what we do. Yes. And then also some communication as well.
Yeah, but I find we're always chatting about the swallowing bit, every day.
Okay, so for our patient then, can we sort of walk through the assessment before we actually go in and see her. Sure, yeah.
Christina showed me part of the SLP assessment, which is similar to aspects of the medical exam. Looking for facial symmetry,
puffing out the cheeks to check cranial nerve number seven and looking inside the mouth for dental health.
And then we move on to the fun part, which is...
Which is looking at the different textures of food that they might have to eat. So okay, this is what I'm most curious about,
because I have never actually seen it. We always talk about it.
So the general principle is that thicker fluids go down slower and are easier to swallow.
The thickest is pudding. The next is honey thick, not actually honey, just the texture of honey. Nectar thick and
then regular thin fluids like water.
Then we try solid foods. The easiest to swallow is pureed foods like pudding or yogurt, because you don't need to chew it.
Then mints textures like egg salad,
soft foods like cheese and bread and then regular solids like a cracker.
Last you try a mix of textures, solids and liquids,
things like this fruit cocktail or cereal with milk.
Okay, so not the best. That wasn't the best.
So we were only able to give a very small amount, because it looked like her swallowing was very impaired. Yeah.
So my recommendation would actually be to do a video fluoroscopic swallow study.
Yeah.
A modified barium swallow, so we can actually do an x-ray of her throat and see exactly how she's swallowing and if there's any
exercises I could maybe give or any strategies we could try to use to help the safety of her swallowing. Yeah, okay.
So I'll go put the order in the computer now. That would be great. Do you want to call down?
Maybe we can see... Sure, maybe we can get her in for this afternoon. Exactly what I was thinking! We can try. Yeah. Okay.
Hi, it's Christina Bruce, speech pathology. I was wondering if you could fit in a video swallow for this afternoon.
Before the video swallow
I'm heading down to the hospital kitchen with Christina and Alicia the dietitian.
They both need to stock up with some food supplies before their assessments this afternoon.
Wow, places I have never been in the hospital before. It's really cool!
Yep, so we have three different types of barium that we use. The first one is a powdered barium.
Did you want to try to mix it? Oh yeah! You just put it one scoop in.
Okay, how big? Is this good? Just about like that, yeah. It's good, okay?! It's perfect. I'm putting that in.
Yeah and then you mix it up.
So the other one that we use is the paste. You would just put a little bit on the tip of a cookie.
On the tip of a cookie. Just the tip of a cookie. Like that? Perfect. Ah, okay.
Take a bit of that and the barium allows us to be able to actually see the food on the x-ray. Right.
Shall I try it? Sure.
I'm nervous. I'm actually nervous.
It's not bad, it's just a little bit chalky.
Yeah.
And this will be a little bit sticky, you might like to try the thicker fluids if you'd like.
Or some liquid barium. At the end of the day if I'm sending patients down for this, so I order people to go and get
this done, so I should probably taste it. Okay.
Okay.
Not too bad?! No, I mostly taste the cracker to be honest. Yeah. Yeah, it just looks kinda scary,
but it's actually not. It's not too bad. That's good.
And then we also assess thin fluids. So here we use the liquid barium.
Then we would mix it with thin fluid water
and then we... That's how we would test thin fluids on the x-ray. Which is the thing
we're really interested in for our patient, right?! Often yeah.
Yeah. Often most people want to know if they can consume thin fluids, so yeah, that's the best one to try this.
In order to stay in the room and watch the video swallow test,
we need to put on lead aprons to protect ourselves from the radiation of the machine.
While watching the test, it's clear that our patient isn't swallowing well.
Fluid is slipping down into her lungs and it's not even causing her to cough.
Plus we can see fluid collecting in the back of her throat, which is also dangerous.
Definitely not what we were hoping to see. So I recommend keeping her NPO. Okay.
Maybe we should refer to the dietitian.
Yeah.
To try to figure out a different way for her to get nutrition and then I'll try to give her some
exercises and we can try to rehabilitate her swallowing.
Ah, it's not what we wanted. Okay, okay. Thanks for letting me know. Absolutely. Okay, see ya.
All right, so now that we know that it's a
non-functional swallow, at this point probably the best bet is going to be an
NG tube, a nasal gastric tube, that actually will put
nutrition right into the stomach and bypass the swallowing.
But I'm going to need to get consent from the family and the patient and just discuss the risks and benefits.
So let's do that now and then we'll try to get in touch with
Alicia, she's our dietician, to chat more about what kind of feeds and nutrition to give.
Alright,
so we went through the risks and benefits and the patient and the family really they understand that this is
hopefully something temporary to get nutrition
while she is sort of recovering from this stroke. So I'm gonna grab the supplies and then we'll go and insert it.
Okay, luckily that went in pretty easily.
So I'm just gonna go in and order a portable x-ray to come up here and then
we can see the placement. And this is critical, because we want to always make sure
that that tube went into the stomach and not into the lungs. You can imagine that putting feeds into the lungs is very dangerous
and can actually be deadly.
So yes, this x-ray is super important. So let's do that.
Okay, the x-ray is not here yet. But in the meantime, let's go find Alicia and chat with her about some of the nutritional requirements
that this patient is gonna have.
Oh hey Alicia. Heeeey. Hey, how's it going? Not bad, how are you? Good.
Did Christina have a chance to chat with you about the patient with the right mca stroke? Yeah. Unfortunately, non functional swallow.
Yeah, non functional.
I actually reviewed her chart already. I was just about to go see her.
Oh amazing, that's actually great timing.
Do you mind if I come with you? Sure. Okay. That would be great.
I'm kinda concerned she looks a little malnourished. Me too. And from what her husband was saying,
she wasn't eating well for the past couple months. I mean, I'm very concerned about her risk of refeeding
unfortunately. Yeah, me too. Me too. I'm gonna have to look into her labs and we might have to order a couple more.
Yeah, I did extended labs this morning, so hopefully we can take a look at that.
That's really good. And we can come together and figure out how much blood work you want to be doing.
I think I actually have an idea of what kind of tube feed I wanna use and... Hey, okay good. She's the expert, I will learn.
So, what are we gonna do for this lady?
So she's got the NG tube in now and we just need to figure out the right feeds for her.
Okay then, so usually I look at the past medical history
and all of her lab work too. Okay, so we can take a look at the labs.
And as you know she's a diabetic, so from my side
I'm most concerned about just keeping her sugars in check while she's getting those feeds. So what do you think is best?
Okay, so this one has less carbs. Yeah, it has less carbs and the carbs are slow release. It also has some fiber.
Okay, so it's like your full meal basically. Exactly.
Carbohydrates, fat, protein,
multivitamins.
Cheers. Hahaha
You could have some.
Oh...
That's really good. I think I like the vanilla part.
So there's this last one that I want you to try. Okay. It's called magic cup. Magic cup. Mm-hmm.
And the magic is that it stays pudding thick at room temperature. Oh nice. So it's like an ice cream, we freeze it
and patients really like it.
But it's safe, because ice cream melts to liquid at room temperature. Oooh and then you can aspirate, right?! Exactly. This is smart!
Hmm. Okay. A lot of people really like it. Alright...
Magic, see what this is like.
Mmmm....
This really seems like dessert.
Wow, actually a lot of these things taste like dessert. Yeah. It's kind of like an incentive, right? Exactly. To keep eating it.
And when we have our patients that are very underweight and have lost weight and they don't have a large appetite,
tthese are really good, because they have a lot of nutrition packed into a small container.
That makes sense. That makes sense, yeah exactly. Mm-hmm. Yeah, thanks. I wanna keep eating this. And who doesn't want to eat dessert?!
Yeah exactly, like I've been trying to cut down on the desserts,
so it feels like a big treat today. So as we're talking and just like... You're getting all your nutrition.
Mmmm, nice. So now I know there are snacks and yummy things stashed all around the hospital.
SSshh, don't tell anyone I said that.
So what do you... What do you find? Like do you find that people like these, that they want to drink them or...
Not really, a lot of people don't really wanna drink them. Really?
Yeah, I don't quite get that.
I actually, so I've also heard that and that's why I was kind of expecting it not to taste that great.
But they taste like dessert, they're really good. So I don't know, I'd be interested... Like have any of you guys actually tried it?
Wanted to/ not wanted to eat it. Let us know in the comments below, cuz I'm legitimately interested.
You know, how do we get people to get the nutrition into them?
Okay, so now that I've sort of sampled everything.
Let's make an affirm plan for our patient.
Okay.
We've got a plan to start the diabetic low-carb feeds as soon as the x-ray confirms the placement of the feeding tube.
And then we'll monitor her electrolytes closely over the next few days.
Okay, let's check if the x-ray result is up yet and see the NG tube placement, hopefully it's the right place.
Oh great, we can see the feeding tube coming straight down into the stomach,
which means that it's in the right place and we can start running the feeds.
Alright, so at this point our patient has the NG tube down,
we've got the feeds officially running now and
we need to make a plan moving forward. So what do you think?
So I'll continue to follow her for sure.
We'll do some swallowing exercises and maybe re-assess in a week or two and see how much improvement there's been. Yeah
okay, that sounds good. Yeah, I'll continue to watch her for the refeeding process and support her nutritional status.
Okay, excellent. So chat tomorrow and then we can see where we're at?!
Okay.
But overall I just really want to thank you guys for such a wonderful day.
I have learned a ton and it's been so much fun to get to see the assessment first hand.
So if you guys want to see more videos like this where you get to see different
professions at work, give this video a like and then comment below because we would love to hear what you have to say.
Otherwise, we'll be chatting with you next week. So bye for now!