The Importance of a Second Opinion

A Partnership Between a Dietitian and A Speech Pathologist

By: Amber Wall

Reading through multiple clinical notes as a dietetic intern can be overwhelming. There are notes from the nurses, surgeons, occupational therapists, speech pathologists (SLP), and more. I began to question the role of a speech pathologist compared to a dietitian. Prior to this rotation, I thought that only dietitians made suggestions on food consumption. Luckily, I was able to shadow Farlah, a SLP, and her intern to learn more about their expertise. This experience has provided me with a greater understanding of the importance of a second opinion. 

My time with Farlah and her intern, Edith, began with an assessment using a trial tray. A patient on a pureed diet had requested a diet advancement. The purpose of this assessment was to evaluate the patient’s  tolerance to a mechanical soft diet. The meal container included two pancakes and ground sausage. The patient did not like pancakes and consumed only the ground sausage, so the tolerance of the meal he ate was based on the number of times it took to swallow. Also, mouth-clearing and time of mastication were also taken into consideration. Edith placed her pointer and middle finger on the “Adam’s apple” to check for larynx lifting and esophageal closing to allow food passage. The patient appeared to be consuming the food relatively smoothly from just looking at him. Edith informed me that the “Adam’s apple” should rise and fall with ease if the swallow is complete and proper. Improper swallowing, also called dysphagia, may have a pulsing sensation and delayed or reduced motion. While to me the patient seemed to be tolerating his sausage well, Edith noticed a delay and a pattern of multiple swallowing for one mouth full of food. From the surface, this could not be noticed. After pressing my fingers to the patient’s throat, I was able to feel what Edith did.

The results of the physical screen indicated that a  Modified Barium Swallow study (MBS) would be helpful. Farlah, Edith, and I teamed up with radiology to take x-ray videos of the throat cavity.  After being shown by Edith, I was able to set up the barium-coated foods of different consistencies for the patient to eat during the x-ray observation. Barium is used to coat the food, so it is visible in the x-ray. Water was added to the powdered Barium to mimic thin liquids. Barium powder was mixed with applesauce and a fruit cocktail cup to mimic pureed food and a mechanical soft diet, respectively. A whole cookie was topped with barium to mimic a regular diet. From a side profile visual, I was able to witness the patient chewing and swallowing the barium-coated food, which appeared on the screen as a black blob. With the pureed food, the patient was able to clear the throat cavity properly without any signs of aspiration. When the texture increased to the mechanically soft fruit cocktail cup, things changed. I was able to see traces of residue building up in the esophagus and its surrounding cavities. This build-up with each swallow created a small stream of contents going into the airway. When food enters the airway, this is called aspiration. Food in the airway causes choking as the body is trying to remove the particle. As I watched the screen, I could see small and sometimes silent coughs as the patient tried to get down the fruit cocktail. Multiple sips of water were needed to flush down food residues as well. This moment was mind-blowing. Initially, I would have presumed the patient was safe to advance his diet due to him eating his ground sausage without apparent struggle. Internally, the patient’s body was not working properly for him to safely consume his desired food preference at the time. 

Additional screens can be performed by SLP using their “swallow bag”. This bag consists of apple sauce, fruit cups, cookies, thickened liquid, cold water, tongue suppressors, and many other assisting tools. These ingredients and tools can test swallowing ability and help determine a patient’s food consistency level. Muscular capabilities are then tested through an array of small mouth movements. This includes smiling, puckering lips, sticking the tongue out, and more. Dental orientation is also assessed at this time. The experience and array of information were very valuable to me as a dietetic intern. I was able to visit patients with my eyes wide open. I began to pay greater attention to other factors learned from shadowing Farlah and Edith. I was happy to include these factors in my skill box, in addition to assessing for muscle wasting, fat wasting, and edema, which were already a part of my assessment practice.  After performing these exercises, Farlah and Edith made a prediction about the cause of dysphagia and determined if the patient would benefit from seeing other health providers.

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Reflecting on my visit with Farlah and Edith, this hands-on experience was very valuable to me. I was able to be more alert as a dietetic intern when providing patient care. I also was able to review notes with a better understanding and appreciation for SLP’s recommendations. I realized that the best patient care comes from multiple eyes and points of view. The end goal is to optimize the health and safety of the patients we are serving. Many tools and resources are utilized to assess and assist in patient care. Getting a second opinion from other professionals, especially from those with slightly different backgrounds, is a powerful asset. Having spent this day with another professional has provided more insight into why second opinions are so important in health care. Since then, with each note I read in the morning, I appreciate it a lot more. I pay deeper attention to each patient and request additional referrals when appropriate. I want to be a second pair of eyes to other practitioners whenever I can.  A second pair of eyes and hands can save lives. Second opinions matter.

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