NTSP Specials (S2) SLT Legends: Prof Wallace meets Dr Martin Brodsky (Part 2)

The NTSP's Prof Sarah Wallace was recently speaking in Cancun, Mexico at the Sociedad Latinoamericano de Disfagia (SLAD, the Latin American Dysphagia Conference). 

Sarah bumped into SLP legend Dr Martin Brodsky, PhD, ScM, CCC-SLP, F-ASHA. Martin is Section Head of Speech-Language Pathology at the Cleveland Clinic, Ohio, and an internationally recognised clinician and researcher in swallowing, voice and airway disorders. His work has a particular focus on the consequences of critical illness, including swallowing problems and laryngeal injury following intubation and mechanical ventilation. Before joining Cleveland Clinic in 2022, Martin spent around 15 years at Johns Hopkins University, where he retains adjunct academic appointments in Physical Medicine and Rehabilitation and Pulmonary and Critical Care Medicine. A Fellow of the American Speech-Language-Hearing Association, his research brings speech and language pathology firmly into the multidisciplinary critical care environment, exploring how we can better identify, understand and treat airway, voice and swallowing problems in patients recovering from critical illness. 

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Transcript

SPEAKER_00 0:08

Welcome to the talk. We've got a real treaty here with a three-part series with two legends of speech and language therapy. The NTSP Sterabolist has recently been at the Latin America Dysphagia Conference in Cancun, Mexico. Sarah running to Dr. Martin Brotsky and we pick up the second part of their conversation, this episode, where Sarah and Martin discuss the importance of timing and the relevance of protocols to guide our work assessing dysphagia and managing the problems that we find. The interview continues over in the hotel palace. There's a little bit of background noise, but we'll call that atmosphere. Over to Sarah and Martin.

SPEAKER_02 0:53

So you and I both speechologists, and I think one of the things that is a constant dilemma, constant point of discussion for our profession is timing of our input, um post-extubation, um post-tracheostomy, sedation green. And we know that it's often delayed. What are your thoughts about that? Particularly like post-extuation as well, where they tend to have problems immediately but potentially resolved.

SPEAKER_01 1:29

Yeah, I these are all really good questions, and to put a definitive a definitive on it is really difficult. Um I think consulting speech within an hour after they were incubated is probably too early. Um let's let's wait for the um medicines to kind of rebalance, I don't need to see a patient at 100% FIO2, I you know, nothing like that. I think you and I might both agree that after the patient is excavated, it's probably a little bit late. My personal preference would be as soon as you are deciding to wake that patient up to be able to interact with us, that's gonna be the best time.

SPEAKER_02 2:20

Whilst they're still worried about it.

SPEAKER_01 2:22

Absolutely. They're making the patient more comfortable. The patient is able to most often be on the oral endotracheal tube and be alert while that's happening and interact. Uh, of course, there's all this literature that suggests that there's better outcomes, less delirium, and better cognitive effects overall. But the grand issue here is that the patient needs to be addressed quickly to have those better outcomes. The speech language pathologist or speech language therapist needs to prepare because each patient is different. The complications associated with this one patient may not be the same as the other, and different tools would be necessary, a different approach might be necessary, or at a bare minimum, the first and second plans may not work, and we're on to plan three, and that's the one that works, right? So time goes with timing in extubation. Give me the time that I need to understand what's been going on with the patient, what I can do to get a reliable response from the patient that in fact will reduce the level of frustration that that patient has and will improve the communication with the team at a bare minimum, and ideally with the patient's caregivers and family. So everybody wins if you get in there earlier. It's the later stuff that kind of pushes all of this earliness off to the side that the first time a therapist is called, physical, occupational speech or otherwise, and it's after excavation. They've already missed probably hours, if not days, of opportunity to orient that patient to a tube that's coming out, breathing on their own, that may very well reduce anxiety, depression, and concern at a bare minimum. Escalate that to swallowing, right? And it's now, okay, you took the tube out. It often comes out with the OG tube that is feeding the patient, and oh, by the way, giving the patient their medications. And now here it is 12 hours after the tube has come out, and you expected speech or somebody else to come by to take a look at their swelling, maybe a nurse screen or whatever it is, and unfortunately they didn't pass the screen and it's 5 p.m. At a bare minimum, you're likely waiting until the next day until you get that speech consult at best. Okay? So that's a problem just by itself. But the bigger problem, I think, is because you got rid of the OG tube, there's only one answer here to remedy the nutrition medication hydration issue if you're gonna do it um enterly, and that is you need to drop another tube. And who wants to do that? The patient just had multiple tubes taken out, and you're gonna reintroduce another tube. We're gonna be better to plan ahead. See if we can get that patient with an oral diet or in a bare minimum taking their medications orally and going forward from there. Why are we kind of backtracing?

SPEAKER_02 6:10

Well, it's all on the background, isn't it?

SPEAKER_01 6:11

Yeah.

SPEAKER_02 6:12

But I I wonder if there's a difference between the US and UK here, because they keep their nails actually too when they're extributing.

SPEAKER_01 6:20

So there's the issue.

SPEAKER_02 6:22

So we don't have that. Yeah. It's still there. Unless they pull it out.

SPEAKER_01 6:27

But that's the so there might be very well different philosophies in the ICUs I work in versus the ones that you work in. I would say most intensivists that I've come across, and it doesn't matter the specialty, have argued vehemently against nasogastric tubes. So they don't intubate patients very often with a nasogastric tube. They intubate patients after the tube is in to help them breathe. So the oral gastric tube is placed right next to it. But there are problems with that as well, right? You may be avoiding the rhinitis, but you're also pulling out the nutrition source and the medication source at the same time too.

SPEAKER_02 7:09

So they're gonna have to have a really good mouth there.

SPEAKER_01 7:12

I yeah. And and oral care, well, they should have that.

SPEAKER_02 7:16

Of course.

SPEAKER_01 7:18

That's everybody's relationship.

unknown 7:20

Okay.

SPEAKER_02 7:21

Isn't it interesting talking to different people at this conference in here in Mexico from 17 different communities in Latin America about all the different ways that they manage patients, but also the also similarities.

SPEAKER_03 7:36

Yeah.

SPEAKER_02 7:36

And how kind of everybody is knows best practice in terms of intubation, exturbation, managing those patients. One of my least favourite words in managing patients post-extubation amateur IP is protocols. Often when people are introducing a service or starting and there may be less um less confidence, less competence amongst the team, you do need a structure, you need a framework. It's a replacement protocols in terms of managing patients post-extuation, managing patients' tricky osmic decannulation, for instance. People really like to follow a path. They can be a little bit uh geared to numbers.

SPEAKER_01 8:28

I think the protocol as a guide and kind of a checklist, if you will, of things that need to be covered is a really good idea. Yeah. We all need that reminder.

SPEAKER_02 8:44

Probably more so as you get older.

SPEAKER_01 8:46

I probably exactly. Umbody should take anything for granted, it all needs to be checked. I think when you really get down to it, patient-centered care is the idea that protocol has. But I don't need to follow a specific protocol. If I wanted to talk with the patient and do a language evaluation before I did an oral motor exam with them, that's fine. If the patient I feel doesn't have the level of tolerance for that cognitive or language exam, then I'm gonna go straight to the oral motor exam. Did I bust the protocol? No.

SPEAKER_02 9:33

You you were led by the patient.

SPEAKER_01 9:34

I was led by the patient.

SPEAKER_02 9:36

Well, we all know these patients change so rapidly and they and they fluctuate so well, don't they? They hour to hour day to day, not making quick enough progress to satisfy some people who just think it's just swallowing, you know. No big deal. Um, can't you just make wave your magic wand, make it go away?

SPEAKER_01 10:02

Um you know my response to that is couldn't you do that with the critical care that you gave them before?

SPEAKER_00 10:16

Thanks so much to Martin for that fascinating chat. If you want to hear more, please follow the channel, subscribe, and check out our website at tracheostomy.org.uk. If you missed the first part of this interview, please have a listen and stay tuned for the final part of this interview today. Let's see that.