Choking Risk

Unknown Speaker (0:15): Hi, everyone. I'm Emily. And this is Eva. And you're listening to speech talk. We're your research book club so

Unknown Speaker (0:23): you can do evidence based practice and practice.

Emily (0:26): So let's start talking. Eva, tell me about your week. What's fun? Well, it's not

Eva (0:33): exactly fun for this week in general, but I am trying to fast today from sundown Thursday to Shabbat dinner Friday. And not to introduce our topic for today too quickly, but it's on choking. And while I was reviewing for our episode, I kept reading the list of food.

Unknown Speaker (0:55): I was like, I'm so hungry. Why am I doing this?

Eva (1:00): So, yeah, that's that's what is exciting for me today.

Emily (1:06): Yeah. That's that's not exciting. That's not exciting to be hungry and then thinking about food all day. That's the worst.

Eva (1:12): There's an open jar of peanut butter, and I just keep, like, backing away from it every time I see it. I'm like, pack it up. Pack it up.

Emily (1:20): That's so funny. I that's that was my snack before podcast today was a peanut butter and banana sandwich.

Unknown Speaker (1:27): Oh, preach. Love it.

Unknown Speaker (1:29): Love it.

Unknown Speaker (1:30): It's like all the choking risks.

Unknown Speaker (1:32): All in one. How about you?

Emily (1:35): So this week, I had two things. So we were we've been talking about dementia and staging and having a group. So I'm getting into a flow with my group. Work flow, baby. I know I will say coffee is the great bringer together of the people.

Unknown Speaker (1:58): If you have coffee at your group, they're immediately more jazz about the experience.

Unknown Speaker (2:03): It's the little things in life. You know?

Emily (2:06): Today, we made lovebugs together, and we were talking about past experiences with Valentine's Day and asking if they celebrate. And one of my more spicy like, I asked one of the guys and one of my more spicy ladies responded for him that he'll be celebrating this year.

Unknown Speaker (2:26): Oh, get

Unknown Speaker (2:28): it. Get it. Get it.

Unknown Speaker (2:32): So I felt like it was fun. I got a chuckle from the whole like, that joke was not missed by anybody at the table. That's it was a good one. And then part two to fun things. So, like, not the fun things side of this

Unknown Speaker (2:48): Of of our fun

Unknown Speaker (2:49): the events from the week.

Emily (2:51): Our fun facts. So we got a new admit today, and we're going through the document. And I say we're, meaning me and my student. And we're going through the intake paperwork, and they're being admitted to the facility for generalized weakness, inability to do ADLs. I start reading through, and this person was at a sister facility and left AMA.

Emily (3:18): I immediately smacked down my laptop, turned to my student. I was like, let me just take care of this. I already know exactly how this is gonna go. Don't worry about it. And then get to this person's room to a tee exactly how it was going to go.

Unknown Speaker (3:38): I'm not playing these games. What are you doing coming in here asking me these questions? Who's Bob? Like, okay. If you change your mind, you know where to find us.

Unknown Speaker (3:52): That's so great. That was a real teaching moment there.

Unknown Speaker (3:55): You're

Eva (3:55): like, AMA, you know, that's always a red flag for participation and engagement. Let's just go test the waters before we get too deep here.

Emily (4:05): Yep. No need no need to go any further. Got it. What is today? What what else is today?

Unknown Speaker (4:13): What is episode for today?

Eva (4:15): Today, we're gonna be talking about choking and food eating in particular, not just like general asphyxiation. Do you remember or have you ever seen a choking incident?

Emily (4:28): So not I've never seen anybody choke at my facility. It's like strangely enough, this week too, my kid almost choked on a pancake, and I had to give him a taco and yell at him for to slow down. But I've never seen

Unknown Speaker (4:48): at home.

Emily (4:49): I know. I actually I have one of those, like, suction things in case, like, worse comes to worse. Have you seen those?

Unknown Speaker (4:55): No. About to get on Amazon.

Emily (4:58): There's there's a device where it covers up the kid's mouth and you, like, suck out, like, creates that negative pressure to suction out food that gets lodged.

Unknown Speaker (5:10): That's wild. I'm a have to look into that.

Emily (5:12): Life saving. What about you, babe? Have you ever seen a choking incident? I have seen

Eva (5:18): two, and I think what was funny about it is that in my mind, I'm going, oh my god. This person is choking. Like, the most safety scary thing. And, like, my heart rate starts going. I feel myself getting hot.

Eva (5:34): I'm like, this is an emergency situation. I need to go get somebody. And the first time I saw a joke, the person I was, like, trying to get someone from nursing because I was like, I can't lift this man. I don't like, I can't get him up out of this wheelchair and, like, heimlich him. He's got a foot easy on me.

Unknown Speaker (5:53): And so I'm, like, trying to flag down nursing, and Sydney is like, yeah. Let me go get, like, a nurse nurse.

Unknown Speaker (6:00): And I was like, why is everyone so chill right now? I'm freaking out. Turns out he ended up clearing it by the time somebody else got in

Unknown Speaker (6:10): the room, so that was fine. And then the next time, this guy's joking, and I'm like, running into the hall, finding a nurse, find the respiratory therapist. I'm like, you know, B. Bed is choking over there. Like, I need help.

Unknown Speaker (6:23): She's like, well, he is on a DNR, D and I, hospice, like, you know, I've talked to him a lot. He has respiratory, like, compromise, and we're gonna we're just gonna have to see how it goes.

Unknown Speaker (6:39): And I was like,

Unknown Speaker (6:40): how is everybody so calm again?

Emily (6:44): I I thought even if someone is a DNRCC, that only is for chest compressions, I didn't think that was for abdominal thrust or, like, immediate life saving measures. I don't know. That I mean, I feel like that's why we're in the therapy side of things and not in, quote, unquote medical side of things because holy heck. I gotta get someone's choking and someone's, like, actively dying. You're supposed to just okay.

Unknown Speaker (7:14): This is this is fine. This is this. Right? This is a part of life. Like This is fine.

Emily (7:20): As they're like Yeah. No. I often whenever I think about choking too, have you ever heard of Elise Myers? No. It she is a, like, a TikTok comedian, and she talks about

Unknown Speaker (7:34): You know,

Unknown Speaker (7:35): don't know about TikTok.

Emily (7:35): I don't I'm not even on TikTok. I think it was on Snapchat. But it well, she talks about eating, like, her most delicious cheese. And as she swallowed one bite, the string was still connected. She was distracted.

Emily (7:50): So, like, anytime I think about choking, think about Elise Myers describing her string cheese incident. String cheese incident. It's a band. It's a band. It's another band t shirt.

Unknown Speaker (8:04): No. That's a real band.

Unknown Speaker (8:06): Oh, is it? No? For real? I'll have to look them up. Hold that thought.

Emily (8:15): We'll be right back after this break.

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Eva (9:23): Anyways, Emily, you should introduce this article because you found it, and I thought it was pretty great. So kudos, girl.

Emily (9:31): So this week, we're talking about a research article called Dying for a Meal, an integrate Great title. An integrative review of characteristics of choking incidences and recommendations to prevent fatal and nonfatal choking across populations by Broadwind Hensley, Joanne Steele, Justine Joan Shepherd.

Unknown Speaker (9:55): And a lot of other people. And more.

Emily (9:58): There's more. And the reason I was looking for an article like this one was because I was working on a restorative dining program. I've been making recommendations for my facility lately about people who are more of a choking risk and would require more supervision and trying to explain to that and and then trying to explain to them why someone might be more of a choking risk than other people. So this was part of what I found. So, Eva, what's choking?

Emily (10:35): What are we talking about?

Eva (10:36): So some of the studies defined choking as a total airway obstruction, and other ones were a little more vague, like coughing and distress.

Emily (10:46): I thought it was interesting what they included because there was obvious choking where they were talking about a clear airway obstruction to the point where this person is there's no air moving, red face, loss of consciousness. But they also included studies where choking was codified as coughing and choking. And I think that kind of pulls to the fact that facilities don't like to say that somebody is choking. They say coughing and choking, or they'll they'll say, like, oh, there was a concern for choking, but the person was just out of breath and coughing. So I thought it was interesting that they'd also added that nuanced bit of information because I I think we do we do end up saying coughing and choking instead of this person had a complete loss of respiratory function for x amount of time, you know, like a more detailed

Eva (11:50): Those tricky, tricky technical definitions. Yeah. But I I think it is important to take a second and talk about what is choking because while it may seem obvious, we think about, like, someone in the movies at a restaurant being like, and they can't talk. And I think part of what is important in defining it and trying to understand how it occurs is part of the ongoing discussion we're always having as SLPs with food. And there's, I think, this kind of debate going on about scaring people with aspiration pneumonia and choking.

Eva (12:27): And I've seen I don't even know how many patients, and I've only ever seen two choking incidents. So to me, I'm always kinda like, how frequent is choking when we talk about the potential risks of, you know, diet modifications and stuff like that? So it was really nice to have an opportunity to look at the research and see, you know, who is most vulnerable to choking? What are the best ways to prevent it So that I think I can feel a little more comfortable with discussing choking with patients.

Emily (12:56): Yeah. I think you're right that people almost use it as a scare tactic. Like, you can't have bread. You're gonna choke. It's like, well, nobody wants to choke.

Emily (13:04): So who is most likely to choke? In the article, they're talking about a higher risk being associated with older adults, people who are intoxicated, those on

Unknown Speaker (13:18): Stay sober.

Unknown Speaker (13:19): Say that again?

Unknown Speaker (13:20): I said stay sober. Yeah.

Unknown Speaker (13:24): Nobody in our facilities is intoxicated. That's not true.

Unknown Speaker (13:29): I have seen the confiscated cabinet, and you could throw a party with what's in there.

Emily (13:35): I forgot. You did work at a crazy facility at one point. So people intoxicated, people on psychotropic medications, individuals with neurological disease, people with intellectual or developmental diseases, and those with dysphasia. So everyone on caseload.

Unknown Speaker (13:53): Yeah. So everyone on caseload.

Emily (13:55): So we have this, like, super broad group of people who are most likely at risk to choke, And then we have our foods associated with the most choking incidences, which was various types of meat, bread or sandwiches, and fruits and vegetables were most noteworthy.

Eva (14:15): The studies were mostly consistent that choking incidents are witnessed by some by someone. It happens around mealtime, but there are no really specific times of day and no consistency in the setting for the incidents. Going back to the idea that there is often a witness present, one of the things I thought was really interesting about this research was that a lot of the studies they got evidence from were bystanders, researchers, and autopsy reports. So they read research where people were interviewed who were witnesses or had experienced a choking event, and they also looked at autopsies. And I was like, oh, it's kinda like macabre slash interesting.

Emily (15:00): I am glad that they used all of that data because, you know, choking can cause death. Like, that is why it's such a serious thing. So talking, including the incidences where, you know, people actually died. It's probably gonna give them the most information. So choking is fatal so is or can be fatal.

Emily (15:24): The studies talked about the different ways people tried to, in the incidents, clear the airway. So they were giving people verbal verbal prompts to cough. They put a person in their recovery position. They called emergency services. They were doing finger sweeps, back blows, helmet, the Heimlich, which is asterisk, no longer allowed to be called the Heimlich for legal reasons.

Unknown Speaker (15:55): Oh, wow.

Emily (15:55): Abdominal thrust, the table maneuver, some suctioning. It was the the list goes on. So they did a lot of different things to try and help these people who were choking. Was it effective? Not all the time.

Eva (16:11): Sometimes it's just a little a little too far gone, unfortunately.

Unknown Speaker (16:17): One of

Eva (16:17): the things that I really liked about the article was they provided personal insights from people who had experienced or witnessed a choking event. And some of the feelings they listed were shock, trauma, embarrassment, humiliation, feelings of dread, fear, anxiety, working you know, anxiety and worrying about choking again in the future, which I feel like is very understandable. You choke once. You're like, I cannot do this again. But I also thought humiliation and embarrassment were really interesting and very strong words.

Eva (16:59): You know, people were talking about, oh, they're everyone was looking at me. It was so embarrassing. And whenever I have a patient use words like that, embarrassing or humiliating, I always feel like it's kind of a pause moment. Like, that was a really strong word you used. How are you doing?

Eva (17:17): I don't think we use humiliation lightly.

Emily (17:20): I can imagine that having everyone look at you in such a state of vulnerability might really feel like, might warrant the use of that, you know, big meaningful word. Like, you might really, really feel humiliated. That's understandable. I guess that's, like, where we come back in. Like, how are we addressing this fear of eating?

Emily (17:44): Counseling. Have you ever had to counsel anybody for?

Eva (17:48): That's a really good question. I don't know that I've ever had to do any kind of, hey. We're really sitting down and counseling. I've had a lot of sessions where we we had to stop the task and talk about it. Like, stop micromanaging my meal.

Eva (18:11): I hate it. Like, oh, hate is a really strong word. Let's maybe talk about why you're feeling this way. And a lot of times, what's beneath that comment is I feel infantilized. I feel like, you know, I can't eat on my own.

Eva (18:28): That's really embarrassing. So I'm hesitant to say that I've ever provided counseling because I'm worried that I didn't provide good counseling if that's what was happening. But I do find myself trying to provide space for patients to discuss what has happened to them because they seem to not just be able to sit down and eat. There's a lot of times something else going on.

Emily (18:53): Yeah. And I guess for some of those people who have experienced a choking episode, they've gone through this new thing of reducing the choking risk, and now we're sitting with speech therapy, or now our food looks different. So that's a new type of embarrassment when you're sitting at a table of your friends, and now your food looks like baby food when it used to look like fried chicken.

Eva (19:18): Yeah. That's that's a really good point that so the the article overall didn't just talk about choking incidents. It talked about events leading up to what happens during and then what happens after. And that's a really good point about what happens after a choking event. You're put on a modified diet.

Eva (19:36): You're put on a one to one feed list. You know? All these things trickle out of a choking incident. And those residual events can also cause embarrassment or, you know, anxiety. It's a really good point.

Emily (19:51): Now that there is this identified risk of choking, how are we going to mitigate that risk? Popular ways to mitigate this risk are modifying food textures or avoiding problem foods. And

Unknown Speaker (20:09): Classic SLP work.

Unknown Speaker (20:10): Classic. Classic. We're just gonna downgrade them

Eva (20:13): all the way. But also specifically, like, avoiding problem foods. So it's not just about what you can eat. Hopefully, what you can eat is way bigger than what you can't eat. Mhmm.

Eva (20:24): And just helping patients identify very specific issues. Mhmm. Emily and I have talked about this in a previous episode of very anti shaped meats. They seem to consistently come up in choking literature as well as Aspergillian events at work. Stop it with the meatballs.

Eva (20:42): Stop it with the hot dogs and sausages.

Unknown Speaker (20:46): Dino nugs are fine.

Unknown Speaker (20:48): Dino nuggets are fine.

Emily (20:51): Great. Despite there being a strong focus on the responsibility of the individual to reduce their own risk of choking by avoiding problematic foods, there was little information in the literature reflecting the views on food texture restriction of the individuals who are at risk of choking or have choked. So, again, we're just missing that person centered care and planning when we're talking about this this shared decision making that is what someone has to eat on the day to day. Like, someone chokes and it's like, okay. Now you're a mechanical soft, never again to see the light of day.

Emily (21:28): And they're

Eva (21:28): like, what? To see a graham cracker.

Emily (21:30): What? I can't have my soup? It's like, no. Sorry. It's mine now.

Emily (21:35): No soup for you.

Eva (21:38): And to that point, part of the reason that restrictions or an overly restricted diet can be problematic for patients is that we run into nonadherence issues. Like, wow. I really can't just eat ground textures all the time for all my meals. So if that is genuinely your recommendation to somebody to only ever eat ground food, you better be talking with them about how to make it appetizing. If they want some more complex textures, what are some good foods that they should try that are maybe transitional textures or something like that?

Eva (22:16): Give them some some options if you can.

Emily (22:18): Mhmm. And addressing, like, the the actual risk. Like, anybody can choke. There are risk factors to choking, but anybody can choke at any given time. I once had a client who I was working on dysphasia, and whilst I was working on this client, her daughter had died choking.

Emily (22:37): It like Oh my god.

Unknown Speaker (22:40): Not not

Emily (22:40): not like, to and it was just it it just happens. It just happens all the time to normal regular people. It just happens.

Unknown Speaker (22:49): That's terrifying.

Emily (22:50): So and, you know, ordinary people aren't going around mechanicalizing all of their food because it happens one time. My husband once choked on a Jolly Rancher, so hard candies are banned from our house. So we have made intentional choices in our family home,

Unknown Speaker (23:09): but not everybody does.

Eva (23:12): That's really funny. Well, I I think what we're getting into is actually one of their big kind of clinical takeaways. They're five categories of prevention strategies. And what we're hitting on right now is sort of the modified mealtimes, textures, avoiding known risk high risk foods. But then as Emily and I love to get into, there's also cognitive modifications, and that gets at that intersection of cognition and dysphasia therapy.

Eva (23:42): Is your person impulsive? Are they a rapid eater? Do they need a calm environment to make sure that they're not agitated whilst eating? You used whilst, so I also wanted to use whilst. Pacing, you know, having sometimes you can do that through portions.

Eva (24:00): Like, we're only putting out a little bit at a time. When you're done with that, you'll get more. Or encouraging pacing, saying, okay. Two bites, swallow, next. Two bites, swallow, next.

Eva (24:12): Right? We're trying to get at that why is food sometimes unsafe even if our swallowing mechanics are fine.

Emily (24:20): Even with those pacing maneuvers, you could have different types of utensils that help you pace. Right? We have Provail cups. We have I hate to call them baby spoons, but I feel like nobody knows what I'm talking about unless I say baby spoons. There's, like, no clinical term for small bolus sized spoons and small pronged forks.

Eva (24:40): Yeah. I did not know about that until very recently. It's like smaller utensils. Like, oh, just, like, adult sized handles with little tiny ends.

Emily (24:56): Yes. So, like, the bites that they can get are nothing but small bites. I

Eva (25:03): I have a patient who's working on pacing with pauses both in his speech and in his mails. I'm like, dude, just your one big takeaway is stop. Stop between bites, stop between words so that you're not having these swallowing problems, and that I can understand you. Like, just little pauses all the time, my friend.

Unknown Speaker (25:22): That sounds exhausting.

Eva (25:25): Yeah. But then we also know that the environment and how they're positioned helps as well. In my facility that I work at now, I'd never done like a codysphagia evaluation with an OT, but that's standard practice there. So while I'm looking at their swallow function, they're constantly looking at the patient's positioning, adjustments, range of motion for gross motor, not just oral motor. And I was like, oh, yeah.

Eva (25:53): I guess that is really important. And it would be nice to know if a tilted wheelchair is beneficial for their eating. So that's been kinda cool to see how OT can get in there for, like, co meal treats.

Emily (26:04): Oh, that's so that is really cool. I have not done that is really cool. I like how your facility does that as, like, a baseline. Like, we are going to address both concerns right now, right here, so we don't have to waste time going between disciplines. Yeah.

Unknown Speaker (26:21): It's very efficient.

Eva (26:22): And to that end yeah. And to that end with, you know, the interdisciplinary support for for meals, like, making sure you know if someone needs to be supervised, making sure those one to one lists are appropriate. And documenting and communicating. Like, if someone is having a problem, then the appropriate party should be notified. Go listen to our SBAR episode podcast.

Eva (26:44): Next

Emily (26:49): step down is our medications and how these medications can increase your risk or decrease. You know? Carbidopa levodopa, my old supervisor's favorite medication, can't it's for

Unknown Speaker (27:04): our I was like, Spell it. Levodopa.

Emily (27:09): Wingardium, card cardidopo levodopa. Hermione. That's for you, Andrew. For people who have Parkinson's, taking that at a a regular time when their meal times are happening, maybe when they're more tired in the day and need more control, it actually helps improve their swallow. So without it, there's it's, you know, opposite effect.

Eva (27:32): Yeah. The polypharmacy section where they discussed how medications can affect people's swallows and and subsequently their risk profile, I thought was really interesting. So they have in the categories of medications, they can potentially inhibit swallow safety, sedatives, antidepressants, extrapyramidal medications, antipsychotics, ant anticholinergetic, hopefully, I said that word. Right? Neuroleptics and hypnotics.

Eva (28:05): So some of those meds can cause, you know, sleepiness, poor motor control, saliva production. There's all these things that can impact pharmacologically how somebody is swallowing. But, asterisk, I feel like this is one of those pause moments when you're reading research because they said people on these medications can have a higher risk profile. And with things like sedatives, I think that really makes a lot of sense. You can be lethargic.

Eva (28:40): You're not paying attention. There's food in the mouth. Maybe you're less alert to having food in the mouth. But, also, when we look at people who are on sedatives, antipsychotics, anticholinergic, and neuroleptics, those are for psych patients or for people with COPD and Parkinson's. And we already know that those diagnoses elevate somebody's risk profile.

Eva (29:05): So I kind of, without wanting to sound too obnoxiously pedantic, wanted them a little bit more to tease apart, well, did the person with Parkinson's on Parkinson's medication have a swallow risk profile that was higher because of the medication or because they're a Parkinson's patient? You know? I hope that rant made sense.

Emily (29:27): It definitely did. And there is, like, a whole episode that I've been trying to write for a year now on this topic, and the research is so dense. It's just been sitting there. Yes. Your your stuff does make sense.

Unknown Speaker (29:43): Okay. Great.

Unknown Speaker (29:45): Mini rants.

Emily (29:47): Another way that we can help manage these risks for choking is that multidisciplinary team. You know, we're like he was talking about, working with OT, implementing regular swallow screenings, talking with your nursing. I'm gonna link it into the show notes, but there is a choking risk assessment that goes through each of these categories and gives it a number on either one to two with multiple areas that you can check. And it's for your nursing to say whether or not this person is a higher risk or, you know, you could use it as well. There's a higher risk for choking and they need to be seen by speech therapy or maybe they need to have increased supervision, want to collaborate with speech therapy, or you as a speech therapist want to use it to justify why this person is a one to one feed and can't just be left in their room to eat alone.

Unknown Speaker (30:47): Their interdisciplinary

Eva (30:50): section was really large. They were like, first, let's start with a public awareness campaign. Like like, interdisciplinary to the public, man. Everyone should know.

Unknown Speaker (31:03): Yes.

Eva (31:04): So while we may not be able to make that lift, we can promote education in our facilities. There were some other niche things like making sure medical staff, you know, this is more EMTs, nursing, can tell the difference between choking and a cardiac event and, you know, implementing a structured choking prevention program. And one note I thought that was interesting was that in some of the fatal cases, food was still reachable in the airway, meaning it could have been, like, with forceps removed. And I was like, oh, man. You're just, like, dying, and piece of broccoli is just sitting there, and people think you're having a heart attack when really they could have just reached down your throat and removed the broccoli.

Eva (31:55): Thank you for the autopsy reports. Two, I'm terrified of broccoli now. I think it's important that we integrate discussions of death with levity.

Emily (32:07): I know. Okay. Can't be in this field like I thought that was interesting too because I've it's always been my training that, like, we don't do, like, deep finger sweeps because you can press it deeper into the airway and make it worse. You had that training too? Like, I I'm assuming they could actually, like, see it and grab it, but, like, I think they're I'm I'm thinking, like, a blind finger sweep.

Eva (32:35): Well, yeah. So they did not recommend a blind finger sweep. They specifically said forceps. So back on track for their five prevention strategies. We've talked about mealtime modifications, interdisciplinary approach, medications, and parley pharmacy.

Eva (32:50): I think we have to talk one about one of our favorite topics, which is oral health and dentition.

Emily (32:55): Oh, yeah. They did talk about which I thought it was like, make sure you're brushing your teeth regularly so they keep as many teeth as they possibly can. Like Quote, good

Eva (33:07): dentition and aggressive oral hygiene were repeatedly emphasized. I loved the aggressive oral hygiene part because it makes me think of someone just angrily brushing.

Unknown Speaker (33:23): Just so

Eva (33:25): mad I didn't get that promotion. Brush. Brush. Brush. Brush.

Eva (33:28): Brush. Brush. Brush. And just spit pink. Yeah.

Eva (33:33): Oh, also on this note, well, we obviously don't want oral residue because, you know, harmful bacterial growth, you know, residue that could potentially go back into the airway when a patient is less alert or lethargic. The the oral hygiene section that really blew my mind was, quote, loose dentures can be swallowed. I was like, one, didn't know about that. Two, must have an enormous pharynx. Three, I can't imagine what that looked like when they were looking for the cause of death, and they they got in there like, oh, there's a whole set of teeth where teeth should not be.

Eva (34:21): Not at all.

Unknown Speaker (34:24): Found grandma's teeth. I have them.

Eva (34:29): I think I had some more, like, questions for you about our role as SLPs. Oh, yeah.

Unknown Speaker (34:36): One of

Eva (34:37): the big ones, and I wish I could find this document I was given during my clinical fellowship year, was a dysphasia eval, like, kind of recommendation checklist, and you could check mark all the things that made somebody higher risk for aspiration pneumonia. And one of them was being fed. And I thought about that a lot during this article because we have a lot of patients who would cannot feed themselves and are complex in that they cannot necessarily communicate their needs or discomfort. And so you have to really, really rely on extremely attentive supported feeding. You You know, the person has to really be checking their mouth.

Eva (35:26): Did they swallow? Is there oral residue? Does it look like they're transiting food in the pharynx? Like, how's the airway doing? And those patients are are particularly vulnerable for for choke risk.

Eva (35:40): So I thought about that as reading as I was reading and also because I have a patient right now who has a progressive musculoskeletal degenerative disease. He's pretty young. And when he swallows, it's puree, and it just sounds like it sounds like choking, and I know he's not. We've done an instrumental, but the the sound he's making is like as food is being pushed back up into the pharynx because he has laryngeal pumping going on. So he swallows.

Eva (36:17): Food is stuck there. His larynx is moving up and down, and it is kind of inhibiting the puree to go all the way down to the esophagus. It's like pushing it back up, and then it goes back down, then back up, and it goes back down. And it's so talk about people's anxiety having a choking risk, so much anxiety in feeding this guy, man. It's like you're just hearing these sounds like he is struggling.

Eva (36:45): And that's that's such an I think about what it's gonna be like for him to go home and his parents to have to do meals like that every meal. It's not easy. So we got him on a peg. So he'll be getting supplemental nutrition, and oral food will be more in the, like, pleasure feeding category, I think, moving forwards. But yeah.

Eva (37:12): Thought about him a lot while reading this article.

Emily (37:17): Yeah. That is that is hard. I've I've had a couple patients like that too where, you know, we've we've done all that we can do, and no matter what, this person sounds like crap. Like, they just they never sound like they are doing well. They're, like, coughing at every every meal.

Emily (37:39): They're just they sound wet and gurgling all the time. You do the education, and a week and a half goes by, and that one STNA or your nurse is like, I'm really worried about 32. And I'm like, yeah. Yeah.

Unknown Speaker (37:59): We all are.

Unknown Speaker (38:02): Well, it is it just is what it is. It just sounds terrible. It's functional, but it just it is is what it is. Sometime Yeah. Sometimes the sound is just a sound.

Eva (38:14): Anyhoo, I think a lot of times safety gets back to the idea of what we're capable of monitoring for a patient and how we can help them also self monitor and and learn to protect themselves. But I I've really come to have this almost existential question at work of, like, what do we actually control? Oh, yeah. Because you watch a swallow study, you do sessions, you train one CNA or one RN, and then the shift changes. Yeah.

Unknown Speaker (38:53): You know? And it's like a blank slate, and you're not there.

Unknown Speaker (38:56): And what

Eva (38:58): do you do? So I don't know. Emily, what do you think we can actually kind of control in our environment to support our patients who have higher feeding risks?

Emily (39:09): Well, for start like, for me, it's a restorative nursing program, like a restorative dining program with listed recommendations that it it's still in the process, but maybe maybe not a sign in sheet that the person complete in the restorative dining room has to sign off that this that they looked over the people who are supposed to be there, and they are understanding their precautions. And then it would be, at that point, weekly checks to say, like, hey. Is this like, are people signing this off? And if they're not, like, why? And how can we address that?

Emily (39:58): I also almost always make a goal in my dysphasia care where over three consecutive sessions, a different aid has to answer, like, 80% of my questions correctly about somebody's dysphasia diet. Like, what diet are they on? What are their precautions? And I, like, quiz people on what they're supposed to be doing. That is so interesting because we do talk

Eva (40:30): a lot about caregiver education and support as being crucial to, you know, patient prognostic outcomes, and I have never thought to quiz people at work. Oh, yeah. That's great.

Emily (40:43): And then I also feel like we have to, at the end of the day, remove that responsibility of people choking from your shoulders. We're not God. We can't stop the inevitable from happening if somebody has a if somebody has a neurological or developmental condition that makes it so that they are shoveling food into their mouth and you, you know, you've told everybody what's going on, everybody has been aware, and they steal somebody else's food and they choke. That's not your fault. So, like, you can't stop something from happening if it's gonna happen.

Eva (41:26): Yeah. And I think that has been a very interesting transition looking between, like, skilled nursing and the hospital is that skilled nursing, it is a very shared place.

Unknown Speaker (41:39): Mhmm.

Eva (41:39): You know? People bring family I mean, people bring families. Families bring people

Unknown Speaker (41:44): food. Mhmm.

Eva (41:46): And, you know, patient in b bed might be mobile and go over to a bed and take some of those snacks. You know? In the hospital, everyone has their own room, and during mealtimes, they go to a dining room where they are supervised. I just feel like a lot of the chaos we see in skilled nursing that increases overall risk for our patients is not as present in the hospital.

Emily (42:11): I don't know, like, if your hospital is, like, private or public, but I think that, like, you can always feel it whenever it's, you know, like, the money is not there. Like, the money is not there for everyone to have their own rooms or to have over staffing of aids. Like, everything is always bare minimum. Yeah. I think a lot

Eva (42:35): of times it just comes down to staffing. I think we've said that a lot that, like, having adequate people on-site helps reduce a lot of safety risks. So, yeah. Anything fun we can end on besides being like, yeah, more resources. Sad face.

Unknown Speaker (42:55): Yeah. Why why do we always end up on a sad note? Sad face. People.

Eva (43:01): We're happy swear to god, we're happy people. I don't know. I feel like we wanted to come out of a choking episode feeling all up and excited. Yeah. I would say that the recently, like a lot of our cog eating patients are doing a lot better.

Eva (43:15): That mindfulness, bodily awareness is genuinely improving their ability to self monitor their meals. So that's been pretty cool. And it's one of those moments where you're like, we really do things here. We're we're serious. We're serious about the therapy.

Eva (43:31): We can therapize you.

Unknown Speaker (43:33): And if we can't therapize you, we can therapize the staff.

Eva (43:39): I have a a dysphasia cog patient who has he's post stroke, left side weakness, and when he takes really big sips of things, he dribbles a little bit of liquids out of his mouth. And I was doing a session with his family there, and they were kind of giggling. And I was like, well, at least you guys aren't daunted. At least this is something you guys feel like you can handle that the, the spillage is not like, my god. Dad can't eat anymore.

Unknown Speaker (44:08): It's like, oh, he's not figuring it out. Try again. It's like, oh, good.

Emily (44:14): There's a random fun fact about me is that I can't eat granola without it getting stuck in my throat, and I'll constantly be like trying to get it up. So my seven year old will come behind me anytime I'm like too weak to deny myself a granola bar.

Unknown Speaker (44:32): I was like, so why you keep eating granola? I'm

Unknown Speaker (44:34): glad. Bars.

Unknown Speaker (44:36): It's my choice, and I am able to make that choice, Eva.

Speaker 2 (44:41): And as a promoter of

Unknown Speaker (44:43): patient centered care, I support your granola bar choice.

Unknown Speaker (44:47): And then I just have my son behind me, like, hacking.

Unknown Speaker (44:50): Could do this. I could

Unknown Speaker (44:51): do it by

Eva (44:51): myself. And that's how you begin to sound like your patients. Yeah.

Unknown Speaker (44:57): And we start doing exercises together.

Unknown Speaker (45:00): That's right. I think we can call it. Let's call it. I think we hit all the things.

Unknown Speaker (45:04): That's all for today. Now may your data be convincing and your patients cooperative. You've been listening to Speech Talk.

Eva (45:14): Thank you everyone for coming to listen to our research book club. Until next time, keep learning and leading with research.

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Emily (45:44): dot com. If you want even more speech talk content, check out our website at speechtalkpod.com, where you can find all of our resources we made for you, copies of articles covered, and Eva's blog following these topics and more. We're your hosts,

Unknown Speaker (45:59): Eva Johnson and Emily Brady.

Emily (46:01): Our editor and engineer is Andrew Sims. Our music is by Omar Benzvi. Our executive producers are Erin Corney, Rob Goldman, and Shanti Brooke.

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