This has been the most challenging 4 weeks in my 20 years of practice for many reasons.
Looking for certainty at a time of complete and utter uncertainty has led us to reach out and make meaningful connections locally, nationally and internationally which has been a double edged sword. It has brought a lot of meaningful discussion but has also given us a thirst for knowledge and evidence that is emerging but may take months to be conclusive.
In the meantime, we question ourselves relentlessly; trying to reduce our clinical worth to what is deemed essential and non-essential has been exhausting and, at times, a little degrading.
The endless debate on PPE has allowed us to fear our patients. We fear the risk we pose to them. We fear the risk they pose to us. We have also been asked to question our worth to the patient’s care. Do you really need to do your job?
The reality is that rates of under-referring to the HSCP group was prevalent pre-COVID-19. This is not a time to exacerbate this situation. This is a time to come together to prove the integral role we all play in a comprehensive holistic pathway of care.
For the first patient I went to see 4 weeks ago, I was so dysfluent in the process of donning and doffing the PPE, I arrived a little distracted. The discussions on how far to stand away from the patient made it harder to do what has always been a fundamental part of my assessment. To look someone in the eye and apologise that they are in Hospital, but reassure them that they are in the right place.
The second time I went in, it got easier. It has also become easier to offer constructive help to my colleagues; can I schedule my assessment at the same time as they need to be turned? I can help. When do they need oral hygiene done again? I can do this. Are they taking meds? I can assess whether they can manage these orally.
There is a debate raging that oral hygiene may no longer be part of our essential role. I cannot agree with this. Not when I have assessed and treated multiple patients in the last few weeks; some extubated after prolonged ventilation, some on NIV hoods, some on airvo, some self ventilating.
COVID-19 requires a very different approach to normal respiratory conditions. Humidification is not necessarily part of the treatment. Dehydration is common and sometimes life threatening. Oral xerostomia and risk of candida are common.
An essential part of my role has been to ensure that all patients are entitled to oral hygiene via suction toothbrush. It is more common practice to administer oral hygiene via small pink sponge swabs. I’m not sure how this ever became normal. An ex-patient likened it to Christ on the Cross and the sponges of vinegar!
It is undoubtedly more comfortable for a patient to have their mouth cleaned with a toothbrush, and when they are unable to manage their own saliva, the risk that this oral care poses to the lungs is significant and life threatening.
It is essential to raise insight into this and help people understand that the suction toothbrush not only saves the patient from aspiration but also protects the person completing the oral hygiene as it is a closed suction system. Being able to support the Nursing Team so that it can be provided every 2 or 3 hours prevents the build-up of candida on the tongue. This is vital to prevent another source of aspiration and pneumonia.
I have now completed an episode of care with a person who was admitted, although within the younger age category, with multiple comorbidities. He was intubated for 10 days, experienced seizures and delirium as a result of severe dehydration and had not been able to see or speak to his family for 35 days.
What did a week in that pathway of care look like?
- Working with my Nursing colleagues to provide oral care, to commence cautiously on oral intake and to determine how to enable the person to communicate basic needs
- Working with my Medical colleagues in Infectious Disease, Renal Medicine and Neurology to define delirium versus neuropathy, confusion versus cognitive change and to determine capacity to meaningfully participate in decisions on delivery of care. All of whom are interpreting the diagnostic results analysed and reported from my HSCP colleagues in Medical Science and Radiography.
- Working with my Physiotherapy colleagues to minimise risk of aspiration from oral secretions and oral intake, and to enable the best expiratory flow for voice, cough and swallow.
- Working with my colleagues in Clinical Nutrition and Dietetics to enable the best regime for nutrition and hydration in the context of a severe oro-phayrngeal Dysphagia.
- Working with my colleagues in Pharmacy to ensure the right consistency of oral medication.
- Working with my colleagues in Occupational Therapy to enable positioning for therapy and self-feeding.
Finally, the icing on the cake at the end of an intense week, was enabling my patient to have a cup of hot (modified) tea, while we whatsapp video-called his family as I interpreted, so they could understand his dysarthric speech. The joy in the reunion, after 23 days of not seeing each other, was immense.
All in all, not a bad week in the office.
This Blog was written by Aideen O’Riordan, Deputy Speech and Language Therapy Manager, Cork University Hospital