Third week

It's the end of another great week. Despite dreading the beginning of another tiring, busy week, I find myself coming home every night/day feeling increasingly positive about my experiences. Well, time to recap. I'll try to keep it shorter this time :-)
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M Jan 16
(day off!)

I've been wanting to add this poem for ages. It was part of the orientation manual.

The Orientee’s Dilemma

There is something I don’t know
that I am supposed to know.
I don’t know what it is I don’t know,
and yet am supposed to know.
And I feel I look stupid
if I seem both not to know it
and not know what it is I don’t know.
Therefore, I pretend I know it.
This is nerve-wrecking
since I don’t know what I must pretend to know.
Therefore, I pretend to know everything.

I feel you know what I am supposed to know
but you can’t tell me what it is
because you don’t know that I don’t know what it is.

You may know what I don’t’ know, but not
that I don’t know,
and I can’t tell you. So, you will have to
tell me everything.

R.D. Lang, Knots
(1970)
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T Jan 17
Showed up at 8am for "paperwork" time, and to prepare for the 10:00 evaluation. Still had no "paperwork" to do, so D tried to find me someone else to observe, though that fell through. Gave me a list of topics she tries to cover with the parents during the interview portion, and a sort of outline of the session. D completed the evaluation by herself in an hour and a half. She's so good! At WJSHC, 2 student clinicians (and our supervisor) takes 3 hours! And then I was given the job of writing this patient's eval report. D emailed me an example report, which is only 3 pages with large headers and the last page is pretty much a section for the pediatrician.

After lunch, inpatient was busier than usual. Sat in on another PICU rounds (my option, versus watching another PMV session (passy muir valve), and came out feeling like I understood a lot more than my first day. Got to watch more consultations, evaluations, and more therapy. Was told that Thursday I will start doing chart reviews. Also told L that I wanted to help her prepare for her leading a competency conference as my project.

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W Jan 18

Kids were great to work with. Gave GFTA to the first kid. I had to do 3 activities with each kid. D gave me verbal feedback after each kid. D returned my first draft and only had a few things to add/change ("few" compared to WJSHC!!!). Had to turn it in Friday, along with a re-assessment report for the first kid re: the GFTA results. Only 1 page :-)

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R Jan 19

Chart reviews are harder than I thought. The SLPs created a single page outline designed to summarize every client they see. By the way, I've realized that the reason it seemed SLPs in the main hospital spent a lot of their free time discussing the different cases versus their vacations and other random stuff (compared to the outpatient setting) was because they all see the same kids when necessary - whenever one SLP can't make it to see a kid, they just tell another SLP and off they go! They're so kind to each other, always offering to help each other. So that's why they have to be well informed about everyone. It's crazy.

Anyway, this one-page summary goes into the kid's traveling folder so that anyone who needs to see the kid can pick it up and not worry about goin through the massive patient chart/binder on the floors. Which brings me to my origional point - chart reviews are harder than I thought! I figured all I had to do was flip through the binder and find the info to fill in the blanks! Come on, how simple is that?! Well, patient charts are humogous!! Like the size of my orientation manual. And although papers are organized into sections and put into chronological order (sort of), reading everyone's handwriting is the pits, and you have to pull out the important information out of a bajillion notes in the binder to put into the summary. And then there are the random bits of info scattered throughout the chart to look for. SO annoying. Oh well, it was just my first time...

Also something super exciting - I got to feed a baby!!!!!!!!!!!!! 2 month old girl, less than 2 feet tall, tiny little thing. She's quite fussy, but L said I did well, even though I didn't get her to drink all her formula. L said even she has trouble getting her to finish her bottle. :-) SO CUTE!

Rest of the day, watched 3 VF swallow studies and an eval. All in all a good day.

Oh, while she went to a meeting before lunch, she gave me a stack of articles about childhood TBI, and wanted me to start researching about it for her. Hehe So I find an empty binder, holepunch and oragnized her articles, then typed up a list of references that sounded interesting on the other articles. She was amazed at how efficient I made things. It's just that the school and research project mindset is still fresh in my mind. And I was quite excited to finally do something I can feel confident in!

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F Jan 20

3 kids back-to-back in the morning, doing 3 activities with each kid. Gave the Kaufman Speech Praxis Test (KSPT) to 2 yr old girl w/apraxia. Last kid cancelled (lives an hour away and the weather was bad), so I couldn't give the GFTA and Verbal Motor Production Assessment for Children (VMPAC) to him. Instead, saw the kid with autism whose new insurance company cancelled his speech services. D chose to see him out of the goodness of her heart even though it was late Friday! Fortunately, I had an activity prepared just-in-case.

After I helped clean up, we just talked for another hour! She's so great. She gave me a folder with info she had given in an in-service she gave about phonological awareness. One big part of it was about something called the Lindamood-Bell "learning process" (check it out at www.lindamoodbell.com/learningcenters/index.shtml ) and she walked me through it. It's so cool! Sounds like a great program. She also lent me an instruction video by that company. Haven't watched it yet, but D assured me the lady in it is annoying, but good to watch anyway.

So that concludes my week. Looking forward to another full week of madness!

Second Week

M Jan 9
Feeding clinic met at 8am where 7 SLPs talked about the kids they're gonna see that morning, and at 9:10 split up to see said kids, starting at 9:15 (I still can't believe they only need a few minutes or less to prepare!). These are patients and caregivers who had previously done a VFSS (Videoflouroscopic Swallow Study), and are here for follow-up to see how they've been doing, and to see if we can upgrade (sort of) to the next level of developmental feeding. That is, can they accept thinner liquids? Drink more? Start using cup-drinking or spoons? Solid foods? Stuff like that. And also schedule the next swallow study or follow-up session. This was till noon, and there were several cancellations. Sessions lasted about 45 mins each. This is something I will be expected to do as well. This is less intimidating than the actual swallow studies. Maybe it's because this was held in the outpatient clinic, even though it's with the inpatient supervisor, and the feel is just different.

Back at the main hospital after lunch. At 1, we tried to see a 2-month-old patient in her room, but she was asleep and the nurse said she was very fussy today anyway. Next patient we saw, her parents were there and were saying how much she's improved, ready to be discharged tomorrow or the day after. Was able to ask L more questions about their expectations for me, and was very relieved to find that they're not high hehe. Nothing against me, but the fact that it takes over half a year to train even a licensed professional SLP to do a VFSS on his/her own, not much is expected of a student. And also, in the inpatient setting, parents are usually reluctant to let a student touch their baby, so it's mainly observation. Most of my learning and independence will be in the feeding clinic from this morning. Whew! Y'all can imagine the burden off my back! Praise God ^_^

The rest of the day, not much was happening, as her consults were scheduled for different tests, and couldn't eat anything for them. Others were asleep. Instead, we worked on getting my passwords to work for the systems, and later I spent a good part of an hour (at my request) looking at and testing the different nipples and messing with thickners - rice cereal vs Simply Thick. Hehe it was fun. Very good for me to have played with them, so now I can understand more of what's going on. Feeling much better today than ever!

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T Jan 10
8-10am scheduled "paperwork" time, though I have no paperwork since I haven't done anything yet. D still wanted me to come in at 8 to prepare for the 10a-12p evaluation, and to look over Wednesday's patient's files in order to choose an activity or two to do with the kids that I've seen before (which were only 2). Patient cancelled on the eval, so being the awesome supervisor that she is, she worked hard at finding someone for me to observe. She encourages me to observe as much as I can while I am affiliated with the hospital. It's really a unique opportunity to get an inside look at the other professions, even if we're not interested in what they do, it's very good for us to know the whole picture of a patient. I highly suggest that every student try to observe other clinics/teams/departments etc, too - especially OT, PT, and neuro!

***(Warning: amusing story in next section. Skip ahead if you're not interested)***

I was sent to observe PT do routine muscle testing for children with spina bifida. Patients have a yearly check-up to ensure that surgical repairs to close the spine do not "tether" their growth or body functions. Some kids are followed well into adulthood even though it's a children's hospital. One PT took me under her wing, and we went to the hallway where patients were waiting in their rooms. We ran into another PT who said to my PT, "X has gotten really cute." Then she asked me how old I was, said we're about the same age, and I should go for him. She then assigns my PT to see him for that purpose! LOL!

So we go in there, and he's in a shirt and his boxer shorts. He goes through all this muscle strength testing, and my PT kept saying how perfect he was (99% of the kids they see are severely impaired). After finishing, we go back to the hallway where she starts her paperwork and where several other PTs mingle, and they all talk about how cute this boy is, and how perfectly he scored on his testing (therefore, he had a lot of muscle).

And so now he and I are going out, and last night we had a DTR (define the relationship) and now it's official. Yes, that's right. I'm officially totally kidding! LOL!

But these PTs were really talking about him being so good-looking, and meanwhile I was thinking he was on the good side of average. hehe but who am I to judge.

Anyway, my PT suggested I observe some neuro testing as long as I was there (this was all on a different floor and department). With a free morning, I was like, SURE! So I was introduced to some doctors, and ended up with a doctor who was supposed to see the same guy! I thought oh my goodness. He's going to think I'm trying to follow him around. Sho'nuf, we were introduced again when we entered his room, and I think his face turned red. I focused my attention on the doctor, because I was there, after all, to learn from her. So she goes through her routine questions (some embarrassing), and she kept exclaiming that he's perfect. Now, I don't know what I was expecting (testing of cranial nerves? IQ test??), but observing this 15-minute neuro exam wasn't very interesting. Maybe because this guy was "so perfect". Ah well, at least I got to see it. And him. The talk of the town. LoL... And just a quick mention that I did get to see her write part of her notes up on the computer, and found that even doctors have to write long reports on a short visits, even when you seem normal. hehe That's why you have to wait so long when you visit doctors. They're writing SOAP NOTES!

***(End of diversion)***

At 1:00 I went to the main hospital. My supervisor had PICU (pediatric intensive care unit) rounds from 1-3, so I was allowed to observe another SLP do a Passy-Muir Valve consult. The kid was an outpatient on a portable vent, and the respiratory therapist had to be there, too, to stick a bunch of wires on his body and monitor his stats. Then watched another VFSS with her. During this swallow study, L came out of rounds and met up with us. We were supposed to see some kids, but again they fell through. I went home around 4. My hours are changed from previously listed because L is pregnant, and needs to work shorter days. I don't mind because I'm physically and mentally exhausted by the end of the day anyway. Plus it always seems like the kids are unavailable after lunchtime.

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W Jan 11
7:50am we see the first kid at the outpatient clinic. D says he and his dad usually come at 7:40 for his 8am appointment. See, it's people like that in this world that I will never understand. haha... I didn't see this kid last week, so I just observe. D likes to start early if they're there early, so that she's got more time between patients to clean and prepare for the next.

9am Kid 2. I observed her once last week, so I do one activity with her. D helped to transition me in and out of the activity. Afterward, she gave me verbal feedback about how I did and what I can try next time. She also wrote it down on an official form. She's very good about telling me what I did right. It's a GOOD quality in a supervisor, if you know what I mean... =) Wrote a SOAP note for her on a separate paper, she reviewed it briefly, said "perfect" and had me write it directly on the official papers.

I was then sent to the main hospital to observe the cochlear implant team during my break and lunch hour. 10a-12p will not be break-time for long, because they are moving the weekly evals to that time slot later on. D also helped to set up that observation for me. She's such a great person :-)

1:30 Kid 3, and 3:30 Kid 4. Did not see these kids last week, so again just observed.

4:30 Kid 5. Saw this kid with autism twice already, so I had to do 2 activities with him. Total bust. He had another 'off' day. The book I chose to use was one he fixated upon in the past, which we found out later from mom. The other activity, he appeared to be testing me out as the new person, so didn't respond well. D again told me he was just having another off day, and that was my feedback.

Later, copied the goals of the Friday kids, so I can prepare 2 activities for each of the ones I had seen before. Home after 6:30pm. Completely wiped out.

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R Jan 12 (Linda = 24;0)
8am L had to train another SLP to do VFSS all morning, so said I could follow her or observe H as she sees her NICU (neonatal) babies. Of course option B! -- WoW! It was a FASCINATING morning! I learned so much watching her handle these premature infants! We saw 4 in a row, within 2 hours. She said she crammed them all this morning because she had to leave by noon. Each infant takes about a half hour to complete the process of feeding. She taught me about monitoring the monitors, watching for the baby's stress signals ("reading the baby"), talked about different positions for feeding premature infants, and so many other things. Can't get over it. She also said it took her about 3 years to begin to get comfortable doing NICU and really understanding it. By the way, my hands were SO dry after that morning, from scrubbing and washing before and after seeing each of the babies. Had to wear gowns and gloves, too.

Over lunch, L reviewed the morning's VFSS tapes with the trainee, and I got to sit in on the step-by-step overview of the patients. It was such a great opportunity for me to learn alongside her, and again see that even an experienced SLP still requires extensive training to become proficient.

At 1:00, L and I finally went up to the floors to see other inpatients. The PICU was a big difference from the NICU. There were 4 on the list of to-be-seen. 2 were for feeding/swallowing problems, 1 was for speech/lang problems, and one was for both. The first was 2-month-old who used to be in the NICU. We changed her diaper and clothes so she'd be comfortable for her feeding. L taught me a way to hold a non-preemie baby (1 hand at shoulders, head and neck, the other at her butt and hip), and a different rocking motion to calm and get the baby in a rhythm for sucking. L taught me to mix the crushed rice cereal (3ml to 40ml of milk for thin nectar, I think) to the right consistency for her. She then fed her till she fell asleep, and then let me try holding her by her way. SO CUTE! What a great experience!

We write up the feed on a nearby computer, and what next? Plans to see the other kids fell through. Of course. One was too irritable, the other two were napping. Fortunately, we got a consult on someone just admitted, and went to see them immediately. It wasn't much, just parents with their 5 month old who hasn't been gaining weight. We watched dad try to feed him, then L tried with her techniques. She explained what she thought, answered questions, and that was it. Home around 4:30.

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F Jan 13
8a Kid 1. Reluctant and refused to work with me, nearly cried at one point. D says she was that way with her for a couple weeks, so spent session building rapport. Good to see how she handled such a kid.

9a Kid 2. Very shy with me. D taught me online how to refine my activity, and demonstrated.

10a Kid 3. Hyperactive, social kid. Had to adjust tx plans immediately because I didn't remember this kid specifically, and planned for a more traditional sit-still-at-the-table kid.

Following, I wrote the 3 SOAP notes on scrap paper, she reviewed them, made comments on one of them, and then I transferred them to the official papers. This, chatting, and her giving me my written feedback took till 12:30. OH, and while chatting, I mentioned it was my birthday yesterday (she mentioned her friend's birthday dinner, so the subject came up), and whaddaya know, while I was writing the SOAP notes, she went to buy her lunch from the cafe and came back with rocky road ice cream for me! She's so sweet!!!!!! Such a great supervisor :-)

2:00 kid was rescheduled to another day, so I had till 2:30 for a long lunch break - finally! 3:30 Kid 4 was new to me as well, so I observed. Her mom kept talking throughout the session ("say it, X, say 'elephant'. 'el - la - funt'. 'elephant'.), and I was getting SO annoyed! Kid didn't have a chance to answer sometimes, b/c she kept talking! I was surprised to see that D didn't tell her to simmer it down. She handled it so well. Later, D told me since she had only met this mom only once before, she likes to build rapport first with her before blatantly advising her to keep quiet, because parents listen and trust her more that way.

4:30 Kid 5 cancelled last minute. I was supposed to give the GFTA and part of the CELF-4, so I can get hours and because he hadn't been tested for a while. Instead, I ended up helping her make magnetic fishing rods, chatting with her, and getting the 10 kids' reports printed out so I can refer to them and prepare for next week. I'm supposed to do 2-3 activities for each now! Ahh! And there’s an eval scheduled for next week – She wants me to do part of the Rosetti scale with her. Hm. Not familiar with this test, but I got a test form to study. It’s similar to the REEL, I think, but more in depth. J She also decided on speech tests that I could give a couple of her patients because she knew I am short on child speech eval hours. I just think she’s the best supervisor in the world! ^_^

Therapy-wise, I asked her if it's OK if I try to imitate what she does instead of creating my own activities b/c I want to learn her style. She said that’s absolutely fine, and that it’s a good way to learn. Her style is so efficient and effective. I've seen her use the same Potato Head, bus & people, food basket, pizza game, etc. to do so many different games that are fun and engaging for the kids! She adapts online to anything so quickly and effortlessly. That makes me want to watch some of our supervisors at Wendell in action sometime, too. Hehe.

First week

Orientation(1-3-06)
8:30-12:00 Two other students present, one audiology, the other OT. First got badges (This picture was worse than my driver's license). Next sat down and received 2.5 inch-thick binder with info about procedures, documentation, child abuse reporting, etc. Thickness may be due to sheet protectors. Must review and return next week. Was told media sometimes tries to get to some high-profile cases, and we should not reveal if we're working with the kid, or any info about it. Also received booklet about Emergency protocol. Test required, but it is open book, a single page, and comes with an answer sheet. Due next Tuesday.

Given schedules. Mine is:
M: Main hospital-> 8-12 feeding clinic, 1-5 see inpatients
T: Clinic-> 8-10 paperwork, 10-12 evals: Main hospital-> 1-5 PICU rounds & see inpatients
W: Clinic-> 7:30-12 2 clients and evals to be moved to this day soon, 1:30-5:30 3 clients
R: Main hospital-> 8-5 Inpatients all day; swallow studies every other week
F: Clinic-> 7:30-5:30 6 clients

Next, we toured several of the floors of the Main Hospital. Size is probably smaller than UIHC but much larger than VA Hospital. SO cute and child-friendly. Every floor has a decorative nature theme. Favorites include "medical free zones" on some floors, which is a big play-room with a community center feel. No therapy allowed in it. It's the area that's least like a hospital.

Afterward, we took the shuttle to the Clark Street outpatient clinic and toured the rehab floor, as well as the cafe. I then had an appointment with my inpatient supervisor at noon, for lunch as an initial orientation with her. Took shuttle back and met with supervisor (will call her L) in the speech office area (shared with OT and PT of course). She bought me lunch from across the street and we talked about very general things about the kids she sees. She gave me a weekly timeline like the one from outpatient, except this one not only includes therapy/evals/project, but also VFSS (videoflouroscopic swallow studies). Then I went with her to PICU rounds (Pediatric Intensive Care Unit) at 1:15, which she says usually lasts till 3 something (ahh!), but this time ended at 2:30 b/c there weren't so many kids lately. Then I went home, feeling impressed and overwhelmed.

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W, Jan 4
Met my supervisor for outpatient clinic at 7:30am because of an 8am client (actually "patient"). I'll call her D. She's really nice, and immediately I felt the difference in supervisors makes all the difference in my confidence level and how outgoing I feel. 5 patients scheduled for the day, but throughout the day, 2 cancelled and 1 no-showed. D suspected it's because she just got back from vacation and people got their appointments mixed up.

Anyway, I was given an observation form with columns labled: pt initials, dx, targeted goals, techniques used, "steps I may take during the next session". These are for personal use, not for turning in. All I did this day was observe. I wasn't pressured to ask or answer questions, and it was very casual. The disorders the children on my case include: artic/phono/oral-motor, VPI artic, exp/rec language, apraxia, autism, down syndrome, and auditory processing. She says she is required to see at least 6 kids a day, with max being 9. Each session being 50 mins long, with 10 mins (or less!) between each to write SOAP and plan for the next kid. Crazy!

D was very nice about helping me find other patients/clinicians to observe since our kids canceled. I watched two sessions where translators were needed (Cantonese and Spanish); one aural rehab, one oral-sensory (baby had food-aversion, gagging at the touch of it evey with hands. Tx involved playing with whipped cream, and facial stimulation by mom), and one feeding follow-up (infant had swallowing problem previously, VFSS done). D also helped me set up observation times throughout the next couple months with an OT, the CI team, NICU follow-up clinic, nutrition clinic, special infectious disease clinic, and possibly the VPI clinic (I said this one I don't mind missing because I've seen it at Iowa).

Came home feeling more comfortable and confident in this outpatient setting.
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R Jan 5
My supervisor, L, was out sick. Arrived at 8am at main hospital, and I was told L wanted me to do my readings whenever there's down time.I didn't bring my readings with me, so they gave me a textbook instead, about Pediatric VFSS. 2 SLPs talked about who wanted to take me that day. I ended up seeing 4 VFSS with infants for the first time, and one NICU (neonatal intensive care unit) infant.

Swallow studies on infants are infinately more complicated than adults! You must consider: baby's gestational and developmental age, feeding schedule, awake/sleep state, nipple size/flow/shape, thickness of liquids in relation to the nipple size/flow/shape (different than adults because very slight consistency gradients make a difference!), what kind of thickner (rice cereal vs Simply Thick, b/c it flows thru the tiny nipple hole differently), what kind is the baby used to using, suck/swallow/breathe patterns, positioning of baby, baby's willingness to feed, weight gain, how often and what times baby eats, how much fed thru NG/G tubes vs how much by mouth, history of swallow problems, and probably a lot more that I can't remember right now!!! And also the infant's anatomy on the moving x-ray is difficult to see because their bones and cartilages are not as dense as an adult's, and therefore do not show up well at all. Couple that with the fast movements of the suck/swallow/breathe pattern (which does NOT always go in a rhythmic pattern like that, let me tell ya!), and we have one complex scenario!

WoW, I was just overwhelmed again! I have never seen anything like it. There were two VFSS I saw where the parents only spoke Polish, and the other spoke Spanish. Translators were needed both times. It seemed simple to call the translator hotline (or whatever) and they sent someone down.

The NICU patient I saw had a cleft lip and palate. Mom was there to learn how to feed him using a Haberman Feeder. It's a controlled-release feeder designed for children with feeding/sucking problems, especially clefts. We watched her feed him for about 15 minutes, while the SLP gave tips on how to control the flow, and watch for the infant's discomfort level.

Came home again feeling intimidated and overwhelmed. That's my word of the month, by the way.

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F Jan 6
Six clients scheduled from 8am-5:30pm. Two cancellations. Therapy is as we've seen and have been trained at WJSHC, so I knew what to look for and etc. D does not take online data, but writes her best estimate of general percentages at the end. SOAP notes are about one paragraph long, without a single complete sentence. I feel much more relaxed in this setting, and was even given a re-assessment report to write for one kid over lunch break. There was extra time during lunch because one client cancelled. Reports are no more than 3 pages, folks! This includes headers, goal-tables, and a large section for the physician to fill out! Cheer up about writing those SOAP notes and reports for school - they are in no way realistic! (It's just as everyone has been saying hehe)

During lunch, D also wanted me to do some readings about floor-time with kids with autism. Then look through the chart of the next patient, and choose one goal/activity to do with a kid I observed on Wednesday. He's the only kid who we see twice a week. It was my first time working with a child on the autism spectrum. She helped me through it, and said that it wasn't a good day for him, and not to feel bad because he wasn't responding well to her either. She said next week, I should start choosing one or two activities to do with each of the kids.

Came home feeling a bit whelmed by realizing that in a few months I will be seeing every one of her clients and doing all the things she's doing now. Not even close to as whelmed as I feel about the inpatient setting, because it actually seems achievable. We'll see how it goes...

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