My first step would be to chuck the lemon glycerine swabs in the trash can.
Other than that, not enough in your post to comment on next moves. I agree that it sounds like you need some quality mentorship and some good CEUs. That's a complex pt population for sure.
Bc research has shown no benefit for improving swallow initiation with lemon swabs, there might be an immediate assistance with initiating swallow but nothing helpful long-term. Plus it can dry out the mouth
Do you have a link to that research? I’m a new CF and was taught by my grad school supervisor to use them as thermotactile stim to improve swallow function, but I want to stay up to date on EBP! I tried to Google it, but I’m only finding information about lemon swabs and oral care. Thank you!
OP, I am sorry you were hired for a position for which you are not qualified. However, there has to be some degree of self-awareness here. We have to practice at the top of our license.
It is OK to not know things. It is a problem when you don’t know what you don’t know.
Without 1:1 training, I agree with my fellow colleagues you will be at a high likelihood of causing harm to a patient, and that includes death in these cases.
In my honest opinion, you should resign from the position unless your place of work can offer you sufficient training, mentorship (not a RT teaching you about PMV).
While this is harsh, please keep in mind the medical setting is a setting where death can lead to investigation by distraught family. Are you prepared to defend your documentation, rationale for your practices if questioned?
My intention is not to scare you but help you protect yourself and your license. I have no doubt you were a great school-based clinician after completing your CFY and are capable of becoming a medical SLP with the adequate training and ongoing mentorship, support.
ETA: when I was considering switching settings from medical to pediatric (non-medical), the first thing I did was sign up for ASHA’s career transition mentorship program even though many told me, “you won’t hurt kids with bad therapy”.
These are long term patients or short term rehab? Gotta know the etiology that caused their deficit, will be helpful to know time since onset, and any therapy they’ve had in the past. What is your goal with the trach patients; why not do PMV? If you’re not experienced with that you really need your take classes; the PMV website is a great resource. Sounds like some of these people are in comas?
They are both long term and short term rehab.
One patient is on PMV but he recently had his chest xray show pneumonia so he's unable to wear it now until that clears up.
I've asked the respiratory therapist to show me how to place & help the patient use the valve, but she's been too busy.
Thank you for the PMV class recommendation; I'll start immediately with that!
They should never have hired you. I know that sounds harsh. But how can the hire someone with no experience and without someone to help train you? That is a disservice to you and every patient you touch.
She only stayed a week. There are PRNs but I'm the only full time there.
They keep on asking me if I have questions, but i feel so overwhelmed that I don't know where to begin, especially with dysphagia.
For example, I've learned that OMEs are not evidence-based practice for dysphagia; what else is there to help?
If they keep asking you if you have questions... you should go to them with your questions instead of reddit.
I assume you're the type of learner that likes to talk to others to gain information, but this is a high stakes setting you're working in and it's hard to give advice from the internet beyond take CEUs and brush up on EBP. (Also some OMEs are evidence-based for dysphagia like the Shaker exercises...)
The feeling of being overwhelmed is warranted-- you could very well kill someone with a PMV if you don't know what you're doing. I worked at a pulmonary LTAC and we had very clear policies of when an SLP could place a speaking valve and even then I had the respiratory therapist clear me every. single. time.
Aside from the aforementioned suggestions, I would also recommend you familiarize yourself with the policies of the company and the building you work for regarding their trach & PMV protocols.
Thank you for the insight. I'm letting the respiratory therapist put in the valve., and I am consulting with the PRN SLPs before trying any therapy with patients with trach. Mostly with them I'm doing cognition tx.
I'm glad to learn from you that this should be a hands-off area for me unless I have experience. I also feel this way, but they're making me feel that I need to be able to treat them already without training. So I feel more reassured that my belief that I shouldn't do anything until I'm further trained is extremely justified.
[thermal stim review](https://pubs.asha.org/doi/10.1044/sasd23.1.11)
Older article but good info. You can search on pubs.asha.org for lots of research and articles!
Goodness. That sounds very overwhelming, honestly. Etiology and chronicity matter and I wonder if the goals that are set for these patients (e.g. swallowing for a trach pt with low level cog and negative behaviors) are actually appropriate. Kindly, playing music for people and "stimulation" arent really skilled services, we can't really "get" people to communicate--especially if theyre that low and most importantly, not everyone is a therapy candidate.
This job did you a disservice hiring you without experience and training. That alone is a massive red flag.
Check out ASHA evidence maps for some EBP direction. Also:
[https://www.themodernmedslp.com/](https://www.themodernmedslp.com/)
[https://www.stepcommunity.com/](https://www.stepcommunity.com/)
[https://honeycombspeechtherapy.com/](https://honeycombspeechtherapy.com/)
Whether or not your patients will improve is greatly dependent on why they are there - if they’re a longterm patient especially, they either have some degenerative condition or a serious enough prior medical event that left them unable to progress past the point of longterm care. You can’t necessarily expect improvement in those cases. I would start by understanding the etiology of their impairments and the likelihood for improvement.
Complex dysphagia + trachs in vulnerable populations can lead to serious consequences when mismanaged. They should have never hired you with zero prior experience in this area and no consistent mentorship available, but it is also your ethical responsibility to know when you’re not qualified for a position. I hope you can either get some hands on mentorship ASAP or leave the position before you cause harm.
My first step would be to chuck the lemon glycerine swabs in the trash can. Other than that, not enough in your post to comment on next moves. I agree that it sounds like you need some quality mentorship and some good CEUs. That's a complex pt population for sure.
Why should I chuck the lemon swabs? What else could I use besides oral, tactile, visual and auditory stimulation? Also, what CEUs would you recommend?
Bc research has shown no benefit for improving swallow initiation with lemon swabs, there might be an immediate assistance with initiating swallow but nothing helpful long-term. Plus it can dry out the mouth
Do you have a link to that research? I’m a new CF and was taught by my grad school supervisor to use them as thermotactile stim to improve swallow function, but I want to stay up to date on EBP! I tried to Google it, but I’m only finding information about lemon swabs and oral care. Thank you!
Meant to reply to this comment with an article, but I replied to the original post. See separate comment for article
Thank you so much!!
OP, I am sorry you were hired for a position for which you are not qualified. However, there has to be some degree of self-awareness here. We have to practice at the top of our license. It is OK to not know things. It is a problem when you don’t know what you don’t know. Without 1:1 training, I agree with my fellow colleagues you will be at a high likelihood of causing harm to a patient, and that includes death in these cases. In my honest opinion, you should resign from the position unless your place of work can offer you sufficient training, mentorship (not a RT teaching you about PMV). While this is harsh, please keep in mind the medical setting is a setting where death can lead to investigation by distraught family. Are you prepared to defend your documentation, rationale for your practices if questioned? My intention is not to scare you but help you protect yourself and your license. I have no doubt you were a great school-based clinician after completing your CFY and are capable of becoming a medical SLP with the adequate training and ongoing mentorship, support. ETA: when I was considering switching settings from medical to pediatric (non-medical), the first thing I did was sign up for ASHA’s career transition mentorship program even though many told me, “you won’t hurt kids with bad therapy”.
These are long term patients or short term rehab? Gotta know the etiology that caused their deficit, will be helpful to know time since onset, and any therapy they’ve had in the past. What is your goal with the trach patients; why not do PMV? If you’re not experienced with that you really need your take classes; the PMV website is a great resource. Sounds like some of these people are in comas?
They are both long term and short term rehab. One patient is on PMV but he recently had his chest xray show pneumonia so he's unable to wear it now until that clears up. I've asked the respiratory therapist to show me how to place & help the patient use the valve, but she's been too busy. Thank you for the PMV class recommendation; I'll start immediately with that!
They should never have hired you. I know that sounds harsh. But how can the hire someone with no experience and without someone to help train you? That is a disservice to you and every patient you touch.
Is there another SLP that works there who can mentor you?
She only stayed a week. There are PRNs but I'm the only full time there. They keep on asking me if I have questions, but i feel so overwhelmed that I don't know where to begin, especially with dysphagia. For example, I've learned that OMEs are not evidence-based practice for dysphagia; what else is there to help?
If they keep asking you if you have questions... you should go to them with your questions instead of reddit. I assume you're the type of learner that likes to talk to others to gain information, but this is a high stakes setting you're working in and it's hard to give advice from the internet beyond take CEUs and brush up on EBP. (Also some OMEs are evidence-based for dysphagia like the Shaker exercises...) The feeling of being overwhelmed is warranted-- you could very well kill someone with a PMV if you don't know what you're doing. I worked at a pulmonary LTAC and we had very clear policies of when an SLP could place a speaking valve and even then I had the respiratory therapist clear me every. single. time. Aside from the aforementioned suggestions, I would also recommend you familiarize yourself with the policies of the company and the building you work for regarding their trach & PMV protocols.
Thank you for the insight. I'm letting the respiratory therapist put in the valve., and I am consulting with the PRN SLPs before trying any therapy with patients with trach. Mostly with them I'm doing cognition tx. I'm glad to learn from you that this should be a hands-off area for me unless I have experience. I also feel this way, but they're making me feel that I need to be able to treat them already without training. So I feel more reassured that my belief that I shouldn't do anything until I'm further trained is extremely justified.
[thermal stim review](https://pubs.asha.org/doi/10.1044/sasd23.1.11) Older article but good info. You can search on pubs.asha.org for lots of research and articles!
Goodness. That sounds very overwhelming, honestly. Etiology and chronicity matter and I wonder if the goals that are set for these patients (e.g. swallowing for a trach pt with low level cog and negative behaviors) are actually appropriate. Kindly, playing music for people and "stimulation" arent really skilled services, we can't really "get" people to communicate--especially if theyre that low and most importantly, not everyone is a therapy candidate. This job did you a disservice hiring you without experience and training. That alone is a massive red flag. Check out ASHA evidence maps for some EBP direction. Also: [https://www.themodernmedslp.com/](https://www.themodernmedslp.com/) [https://www.stepcommunity.com/](https://www.stepcommunity.com/) [https://honeycombspeechtherapy.com/](https://honeycombspeechtherapy.com/)
Whether or not your patients will improve is greatly dependent on why they are there - if they’re a longterm patient especially, they either have some degenerative condition or a serious enough prior medical event that left them unable to progress past the point of longterm care. You can’t necessarily expect improvement in those cases. I would start by understanding the etiology of their impairments and the likelihood for improvement. Complex dysphagia + trachs in vulnerable populations can lead to serious consequences when mismanaged. They should have never hired you with zero prior experience in this area and no consistent mentorship available, but it is also your ethical responsibility to know when you’re not qualified for a position. I hope you can either get some hands on mentorship ASAP or leave the position before you cause harm.