MB, a 60 year old male with a J-tube &  diagnosis of stomach CA had just received his surgery for the latter with a gastric pull up pouch. He was to begin PO trials with the SLP at the SNF,  but she was  concerned about aspiration as well as digestion issues. The staff was unaware the patient was going to have secondary surgery to close the fistula at the site of the pull up surgery which had a catchment bag attached to it. (The site had not completely healed yet and was draining.) Unless you knew to examine the area of surgery this may have been missed.  The LTC SLP intelligently requested a FEES for this patient, whose presentation you do not see every day. The patient was alert, oriented as well as in excellent physical condition despite his primary diagnosis. He was to be returning home shortly.

The patient easily participated in the exam. He was trialed with very small amounts of thin liquids, puree and dissolvable cracker. In terms of the oral pharyngeal component, nothing of clinical significance was noted. However to a trained therapist, a small hiss and splash under the patient’s clothes was heard. Yes……………….the food and drink – everything was coming through the wall of the gastric pouch into the bag!  Had someone been performing the exam who had not seem complex cases like this over the years, this could have been missed.

The SDX FEES Specialist paged the surgeon, the situation was explained and the patient was allowed to have thin liquids as long as the bag was changed regularly and the site remained clean. The patient was given a post op surgery re-consult date before he went home. He hadn’t remembered that the surgery was 2 parts and that the fistula had to be closed. This decreased the patient’s anxiety ten-fold as he was terrified of what was washing through his bag. He plans to be discharged home, complete his second surgery to close the pouch wound, begin slowly transitioning back to small portions of regular foods and decrease or possibly eliminate his J tube feeds.

SDX prides itself on our hand-selection & thorough training of SLPs who have demonstrated excellence in long-term and medical therapy settings.  It’s not always just about the exam, sometimes it’s the expertise AND ACCESSIBILITY of our FEES Specialists that lets you SEE the FEES difference!   

Let’s face it, in our profession we can’t even agree if we should call a swallowing problem dys-fay-gia or dys-fah-gia, so how is it that we should agree on a single instrumental exam?

Well, the answer is we shouldn’t.

We should have both FEES and MBS available for instrumental testing.  We should be free to choose the exam that gives the answers to the questions we are asking.  If I’m wondering why Mr. Smith is coughing during and after his meals, let’s FEES away…concerns for chronic coughing, secretion management, changes in vocal quality and complaints of globus sensation warrant that.  Now if Mrs. Smith is showing me she has food getting stuck in the mediastinal region and she has a history of esophageal difficulties, MBS makes sense.  One of my favorite docs breaks it down like this…bigger concerns with liquids, FEES them.  Dysphagia to solids?  Lean on MBS.  I’m not saying it’s black or white…like an MBS.  Really, swallowing usually deserves a BRIGHTER, more colorful assessment like the FEES.  Consider factors like how quickly testing needs to be completed, if you are concerned for fatigue, if you want to train the patient using biofeedback…then scoping away will make your day.  FEES gives you all those advantages!

Looking at the typical SNF roster, 75% of those residents with dysphagia needing an instrumental swallow test would be best serviced with FEES at the bedside in their typical eating position swallowing actual food served from the kitchen, like rice, salad, spaghetti, sandwiches…not barium coated crackers.  #FEESadvantage!   If we are testing swallow function for a meal, then let’s keep it real!  Order up a regular meal from the kitchen and let’s see during the FEES how those cabbage rolls or meatballs actually go down.

Did I mention radiation typically cuts off my view of an MBS at 3 minutes?  And that’s if I’m lucky to record that much footage!  I mean, that’s like paying MOVIE PRICES to see just a PREVIEW!  Well, when it comes to my older patients, I want to know what happens at minute 12, 15, 18, 25…I need to see the impact of fatigue on bolus control and pharyngeal clearance!  Again, point to the challenger, FEES.  No  time limits with FEES, so I can view that entire meal.

I am so thankful that I was taught by open-minded, savvy SLPs in a strong rehab environment with MD support.  I’m fortunate that I came into SLP-ing at a time when clinical practice was not as constricted by financial resources as it is today.  Back in the day, the only question was “What instrumental study does the patient need?” not “How much will the test cost?” or worse yet “Can’t you just leave them on a modified diet?”

We should always focus on evidenced-based practice and best practices for patient care. 

Be sure to take the time and THINK about the test you need based on your therapy goals, questions and concerns…make sure you are getting the best value for your therapy dollars!   #FEESadvantage #sdxslps #dysphagianerd

We had an SDX FEES patient last week who was in a predicament. He had been scheduled for an MBS who was scheduled a week out. Overall he had debility, end stage renal disease and coughing when eating a regular diet texture with thin liquids. However, it was found before the exam he was actually allergic to barium contrast used in an MBS procedure. Also his renal doctor also became involved and preferred he did not have any barium contrast whatsoever even if he wasn’t allergic. The FEES exam was scheduled and performed within 48 hours. The patient was anxious about the exam as he was prepared for an MBS and somewhat apprehensive regarding scope placement. However, after explaining the FEES exam and participating easily in the exam for 18 minutes, the scope was removed and he couldn’t believe “How easy and painless it was.”  He stated he would recommend a FEES to anyone he knew with a swallowing problem. He also appreciated that he was seen upright in bed without having to go outside of the facility as this is where he prefers to eat. The report and video was available in the SDX-FEES.COM secure e-cloud by the end of day for professional and SLP viewing.  #madeadifferencetothatone #nailedit!

The Position of the Academy of Nutrition and Dietetics: Ethical and Legal Issues in Feeding and Hydration discusses the importance of a supportive interdisciplinary effort using a culturally respectful approach to support families and caregivers through their decision making process.  It emphasizes the individual’s “right to request or withhold nutrition or hydration as medical treatment.”

It is our professional and ethical responsibility, and well within our scope of practice as SLPs working with long-term care residents, to document not only what is safest for a resident but to additionally comment on (1) the resident’s prognosis for developing aspiration complications and (2) quality of life considerations.  Dementia is commonly considered in the research to be a terminal illness, and as such, it is appropriate for an SLP to explain in documentation that while there is risk of prandial aspiration with oral feedings, that the placement of a PEG tube will further increase the resident’s risk of developing complications like aspiration pneumonia.  Furthermore, nonoral nutrition is shown in the research to have no positive impact on quality of life in residents with dementia.  In a time where the focus is on evidence-based practice, it is important to be well-versed in the current research about PEG tubes and dementia, and to be able to fluently discuss both the pros and cons with residents, their caregivers, and other professionals.

SLPs have the power to be the voice of reason when PEG tubes are discussed for residents with dementia.  Rely on the research to guide your professional judgment and step up in the discussion for your residents and for their dignity.

Stated with love for quality of life & liberalized diets, Katrina Woodward, MS, CCC-SLP SDX Scope Squad Leader & Certified Dementia Practitioner