Sixth & Seventh Weeks

Outpatient

Independence Level

By now, I run full sessions for about half of the caseload, and at least 50% of the sessions for the other half (because parents are present and/or the kid is very behaviorally challenging). Denise wants me to be in charge of the time now, since I've a bad habit of forgetting to pay attention to that. This week she'll give me her pager and I'll be unofficially her.

Evaluations

I've only seen two other evaluations since the one in January because oddly enough, they keep cancelling. D eased me into it by letting me do the interview portion and giving the GFTA for the first, while she decided which language test to give, administered the entire CELF (becuase I hadn't seen it before) and the exit interview. The second eval (the one where I still have to complete the report), I did the interview, decided which test to give, gave the PLS-4, and did some exit interview until Mom had questions about insurance and public/private schools and tx in the area, which I don't have a clue about. But then D ended up doing the rest of the recommendations because I had to keep the kid contained (he was trying to leave the room, messing with the lights, trying to bang on D's keyboard and monitor, pulling books off her shelf, dumping all boxes upside down...). D said I have a natural way of interacting with the parent, and that it's OK that I accidentally labled the pictures on one page for the kid before asking him to do it too. She says now I won't make the same mistake again. She didn't make me feel bad at all.

Last Friday, I called the preschool that the kid goes to and talked to the teacher to get some info about how he is for her. It was my first time doing something like that, so D was so good - she wrote out how to introduce myself and a list of topics to ask about. The phone call went well, and now I can include it in the report. Whoopdeedoo :-)

Inpatient

Independence Level

Haven't fed any more babies lately. There's an SLP who they hired last June and she is still in training, so I've been following her with L and observing. I love following Moreen and Laura (who cares if i use their first names?) because Moreen asks great questions and although I of course realize that I'm not at her level, I appreciate that she's learning like I am, and I don't feel so behind that I'm not doing much at this point. I like hearing how Laura teaches her.

I mixed consistencies last week for 2 swallow studies! :-) It's not much, but I finally felt a part of it. Also saw what it's like to do a VFSS on a 2 year old. Cute little girl cheery and fun until she's put in the seat. A switch is flipped and suddenly she's a screaming banshee who might melt if she ate anything at that moment. Two bites of two consistencies are practically forced down her hysterically crying mouth (yeah, not safe, but we gotta see something!). She's lifted from the booster seat, which triggered that magical switch, and she's a sweet little angel again.

Panic Attacks

Oh good gosh, last Thursday morning, the first two babies we saw with Moreen desaturated to panic levels! The first was ventilator-dependent, and her O2 desaturated to the 70's (Normal is > 95%), and the second had a lot of problems going on, and desat even to 59!!! Scary stuff! Nurse came in for the first to suction and 'bag' her, but the second, the nurses weren't as worried because her normal O2 is in the 80s. I wasn't the one handling either of them, so that's a relief. :-). The second baby had a cleft lip and palate, and Laura let me stick a gloved finger to feel it, and feel that her suck was adequate despite it. It was really neat to feel that palate edge!

Occupational Therapy

Last week I shadowed an OT. They have to see practically everyone in the hospital it seems! That was good to observe.

Emotional Turmoil

Next I want to learn how NG tubes are placed. It seems so intense, and yet families are released home with NG tubes and they learn how to change them. Ah, last Thursday, I watched Moreen do a swallow study where the kid aspirated on everything (yes, even honey!). So she had to tell the parents their baby will need a feeding tube, and need to stay overnight at the hospital to learn about it. Dad gasped and reacted emotionally, while Mom was calm and took it in stride. Moreen and I cleaned up the swallow study area and then turned around to walk the family to the ENT floor. Well, Mom was right where we left her, but Mom said "We can go as soon as we can get his dad's crying a** out of the bathroom". Mom said she's not as shocked as Dad because she's been the one getting all these news about the baby's problems, cuz Dad's not always there. Gosh, it was hard to walk with them upstairs as dad was sniffling and hiding his face under his cap that was pulled way down over his eyes. When we got to the floor, we had them sit down while we told the receptionist that the ENT was expecting us. Then we went back to where they were sitting, and Mom was just getting off the phone with her own mom, and was crying too. I just wanted to tell them that it's OK, that lots of kids have NGs and it's for the best. etc etc. Moreen was just real quiet after she gave the news. It was her first time breaking the news to parents.

Feeding Clinic

Today I also observed breastfeeding for the first time. That's all I'm gonna say about that. =)
Well, it was during feeding clinic, and I'm supposed to be independent on these by now, but for a while a lot of the families haven't shown up!!! Especially the one I'm supposed to see! Even last week, I saw two families but these parents have already interacted with Stacey (one of the SLPs who does feeding clinic, b/c my supervisor's the coordinator and pregnant hehe I observed with Stacey for a while). So when the families came to see us, and Stacey said I could take the lead, I would ask questions and stuff but the mom would answer looking at Stacey, and asking Stacey questions hehe. They are just more comfortable with her, plus I'm introduced as "the student" so there's all these good reasons for them to talk to Stacey more. That's OK with me tho! I sometimes have an idea about what to say and stuff, but I am very shy and not willing to risk saying something stupid, so I end up letting Stacey do most of the session. We'll see how it is next week, my last week!

Can't get away from the media

By the way, saw another news crew today. I actually think I'm in the shot this time, because as I'm exiting by the main entrance this time, the reporter's back was toward me and talking to the camera. Except, I'm about 20 feet behind her, and the moment I looked up from the sidewalk (i look downward in the winter when I'm cold hehe), I veered off to the right toward the shuttle buses. So who knows if I'll be on TV tonight. Probably not. Please not. Got to write a report tonight, though, and work on the stuff for the presentation this Wednesday, so no TV for me!

Competency Conference/Student Project/My Upcoming Presentation

I found out today that the competency conference might be videotaped and phone-conferenced to the satellite clinics around Chicago! So it's not just to all the SLPs in this department here, it's all the SLPs affiliated with Children's Memorial! There's another student here, by the way, who is doing feeding clinic (not just the Monday one, but with one of the full time feeding therapists) and AR clinic. I think her student project will be presenting an article about something related to pediatric feeding problems to the small group of Monday morning feeding clinic SLPs during rounds. Yeah, that takes about 10 minutes, and it's nothing we haven't done in class before! Ahh! I guess I chose to help Laura, so that's the difference. Hehe I'm relying on my good ol' fall back of having lots of visuals - handouts and power point. Yes, that's right, be distracted by all the writing and pictures and don't listen to me! hehe

Oh yeah, dunno if I said it before or not, but my 45-minute presentation is a review of the brain - anatomy and function by location, symptoms resulting from damage to certain areas, and types of TBI. Here's hoping they won't ask questions...

Last Leg, Next Step

One week left after this one!!!!!!!! Unbelieveable that it's gone by so fast. Plus, I've decided to get a PhD rather than be a full time clinician. I still plan to do a CFY, but maybe part time during hte first year or so of the doctorate program. Dunno where, dunno when, dunno what area of study. Dunno anything but that I don't see myself being a clinician day in/day out.

Don't forget to leave comments so I know how you're doing and whether I should keep posting!

Kid Hospitals = emotionally draining

It seems like what we did in the clinic at school is a world away from what I'm seeing in "the real world". I can see how a lot of people say they did most of their learning on the job. Thursday I was allowed to pick up and feed a baby by myself! Well, not totally alone, but I mean I used to have to sit down first and have the baby handed to me, but this time I swaddled the baby myself and brought her to the chair myself. Hehe and I didn't stumble over her tubes and like drop her out the window.

I felt so bad for some of the kids I saw Thursday. There was one 2yo girl who had brain surgery on Tuesday. And so she was NPO (nothing by mouth) for the last day and a half, with no NG (nasogastric) tube or anything, just intravenous hydration. We saw her at her bedside to assess her ability to swallow safely. She had a huge gauze pad on the left side of her head, and her left arm in a cast so that she won't pull at it. She had barely any hair, and she was really cranky for food and drink. Her mom was there, with such an anxious / loving / distressed facial expression. Ah, just tear my heart out why don't you????

And then I saw a kid who's also about 3 years old for speech/language tx. This boy was born with Short Gut Syndrome, so he's got his stomach pretty much outside his belly. He's got a G tube to feed him, a J tube to do something else, and another tube to drain his bladder, etc etc. He's been in the hospital ALL HIS LIFE!!! So I go into his room with the SLP, and we start to do play therapy w/him on the floor, and he's wanting to push the truck around, but we kept having to tell him to not go so far because he's quite literally tethered to his bedside with the machines. Oh my, what kind of life is that?? :"-(

And later I gave the Rossetti Infant-Toddler Language Scale (or at least I tried) to a little girl who's about 15 months old. She's also been in the hospital all her life. Everybody loves her - her nurses, doctors, physical therapists, occupational therapists, all the SLPs who work with her ... And yet, I hear from these same people about her parents who have barely come in to see her for her whole life, and how they just don't love her like they should. She's scheduled to be discharged March 1st. I dont' see how that's going to happen for her best interest, because her parents will have SO much to learn about how to take care of her medical needs (she's also tethered to machines). Apparently, her parents are really young, like 17.

Maybe I'm not cut out for kid hospitals. There are lots of kids in here also for non-accidental head truama. That just kills me. It really tears me up inside how ... anyway, let's not get into that. It's too depressing. Ugh, and there's also the media. I've been here a month and a half, and three times I've seen a news crew around, usually ABC I think. Who knows how many more come around that I don't run into. Last month during PICU rounds, I remember hearing a resident or social worker saying this high profile kid who's been in the papers and news for some head injury was afraid to go home when he was discharged becuase he didn't want all that public attention. He was hiding crouched in the corner of hte room refusing to leave! Argh!

Thursday, I left by the employee exit, and almost ran into a news camera that was aiming for the entrance of the building. Turns out, as I was channel surfing that night, that WGN Chicago (i think?) had interviewed a kid last year who had a liver transplant, but is back to the hospital now due to liver failure. So they just taped the exterior of the building, and my ugly face didn't get in the way... Too bad! LoL

Fourth and Fifth weeks

Hi everyone,

Sorry that I am long overdue for my weekly post. It's gotten busier (or rather, I've started to be more hands-on, so it seems busier ^_^) over the past weeks, and when I get home, I am more tired and lazy about posting. So again, my apologies! Anyway, instead of a 10-day diary, this post will be more of a summary of the more memorable experiences (midterm eval, my turn at feeding babies, writing SOAPS and reports, doing therapy).

But before I start, I need to share about the panic attack I had this morning though it's not related to the outplacement. Before I moved here, my dad insisted that I get the massive monster of a microwave oven instead of the typical dorm-sized microwave because "it'll last longer" and I "can use it in the future". So for the past week I've been using it on the 'grill' setting to toast one eggo waffle in 7 minutes. This morning I decided I wanted 2 eggos, and set it for 7 minutes, 30 seconds. Then I go about my morning routine, and within 5 minutes I hear a kind of soft popping sound from the kitchenette. I glance over, and WHOA MAMA the Eggos had burst into flames!

No exaggeration, not even kidding, it was bright yellow and red in the machine with smoke billowing around my tiny kitchenette. First instinct after hitting the "stop/clear" button was to open the door. But once I grabbed the handle and pulled I realized it was incredibly dumb to do so because I would be letting in oxygen. And plus the flames definately got bigger within the milliseconds it took to open and shut. So I decided to keep it shut and let it die out on its own.

Needless to say, I was running late for the hospital while the fire alarm went off intermittently at 7:30am. I opened my door and window. It took a couple minutes for the fire to actually disappear in the microwave, but all in all, everything was fine. So when I heard sirens outside, I freak out and wonder if it's getting louder and under the building. Fortunately, it was just another side effect of living in the city. ::whew::!

When I got to the department office, I find that the SLPs were at a meeting, so I had till 8:30 to get there. In any case, they quickly determined that I had a cold, and insisted that I go home. I insisted right back that I felt fine and promised to not touch anything and keep my hands doused with hand sanitizers. L said I smelled like smoke. In any case, by lunchtime I felt the effects of an 'exciting' morning in addition to my Nyquil finally wearing off.

So I was forced to concede and come home. I sit here typing at my desk right now in my winter jacket and wooly socks with my air unit on high and all windows wide open... on the 12th floor (it's numbered 11, but there's an extra floor labled "M" in the building).

And yet that fresh burn smell lingers.

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By the way, I've taken to writing everything down in a spiral bound notebook. The SLP's questions to the parents, their responses, the baby's diagnoses (if odd), the baby's reactions... everything. This has really helped me for when it's my turn to do things (usually unexpectedly, she'd say "you want to do this?" or "so what are we going to do with this kid?" or "what are we looking for here?" or something like that.) She doesn't mind when I flip through the pages before answering or reacting. :-)

Whenever I go to the main hospital, I take my black Iowa bag and carry the notebook, my clipboard, and a binder with copies of the material they gave me to start with, and other things I've collected on the way. This way, I can refer to them whenever there's free time. Whenever I go with L to see her patients, I carry that special notebook and my clipboard, where I also carry copies of the patient intake form that needs to be filled out for every new consult.

Whenever I go to the outpatient clinic, I take my black Iowa bag and carry the notebook, my clipboard, and a binder with all the patient's old re-assessment reports with their current short term goals in it. The night before, I write my lesson plans for each of the patients (which DeFiNaTeLy doesn't take as long as it used to!!!) while referring to this binder. I use the same notebook to take data for every kid, as well as write a draft of the SOAP note for D to review before writing it in the official papers with carbon copies. Last week she's been saying my notes are "perfect" and that she wonders why she still has me write drafts. I said I like doing that because it's always messier the first time, and it also helps me to plan the next therapy session since I don't get copies of their SOAP notes otherwise.

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... Midterm eval ...

Both my supervisors came together to meet with me in a small room at a small table. It was kind of uncomfortable with them sitting on my left and right side and looking at me, but since they are such nice people, I wasn't too worried. Especially because the day before, L made a comment about the meeting not suspected to take too long, and D made a sarcastic response like "yeah, Linda, we have SO much to talk to you about". Hehe so that put me at ease already.

Anyway, they both said I was doing fine, on track. They agreed that I seem to do better with structure, and that the next step in my learning is how to handle situations where there's not that much structure. I agreed, to the extent that that was goin to be my comment to them, that I prefer things to be more stuctured, and that my challenge in the outpt setting are the kids where I can't follow a strict lesson plan, where the kid is so behaviorally challenging we have to go with their flow. And also that there's almost no structure at all at the inpt setting. They said it's completely normal to be this way newly out of school, and that it's good that that is my next step.

I was also reassured that even though I am still mostly observing at the hospital, it is perfectly fine. L said when they hire someone new, an already practiced SLP, they still have to observe for a month before they start getting hands-on. In fact, someone they hired last summer is still not fully independent as of now. I get to watch L train this 'new' girl sometimes, and I really enjoy it because they talk things through, and she asks questions that really help me understand better.

They said my strongest point is my writing. I write reports and SOAP notes that need minimal if any revision. They said they are very impressed. Guess all that time in WJSHC has paid off. Hahahah... Nah, I think it's more because I read a lot of their notes very carefully, and try to imitate it as best I can. I even copy some notes into my spiffy notebook, so I practiced writing before I had to write for them.

And finally, D asked about how my project has been going with L. L says I've been great, because she hasn't had to do any work yet haha. It's true, I've been doin research on articles and stuff in my spare time (which isn't to say that i have a lot. i live alone with my TV. What can i say?) and writing the outline for the presentation about neurological insults (TBI, tumor resections, and AVM) coming up in Feb 22. Oh dear that's getting close. I kind of get to choose what areas I want to talk about, and I think it will be normal brain anatomy (including cranial nerves, etc.), function by location, and how damage in those areas will show up in a child.

... Feeding clinic ...

I started to feel more ready to participate by writing notes or something, so I told my supervisor (L) and she said sure, I can do something next time. We looked at the schedule for the following Monday and chose a patient I had seen (in observation) twice already. Jan 30 came around, and at 9:15 I observed one session with a different SLP and wrote the SOAP note for her directly after, which was my first ever for feeding clinic. I was told it was very good, and she made very minimal changes, just about wording. :-) Then L and I talked about how I was to participate in the chosen patient's follow-up session at 11:00. I was to do the questioning part, where we find out how the kid's been doing since our last meeting. I wrote out my questions, mentally prepared myself to do the interview, and was ready to go when 'lo and behold, they don't show. Of course.

... Inpatient setting ...

My outpatient supervisor (D) went to a 3-day conference about autism, so I had more time in the main hospital last week than usual. It was good to see some of the same patients daily, since there's usually such a quick changeover that by the time I come back the following week, they are gone. I looked again at the weekly timeline I was given on the first day, and mentioned to L that at that week, I was supposed to "identify one patient" which meant I should choose someone to follow and take charge of. Well, at that point there was only one little 2 month old girl (absolutely the cutest thing I have ever seen! Wish we are allowed to take pictures hehe) I had seen more than once, so she became "mine". That same day, we were supposed to see her, and we got to her floor and L said "OK, you're in charge of the session."

Heat wave immediately poured over me! 'Oh my gosh' i thought. i was NOT prepared for that! I expected more of a transition phase or something. Well, I hesitantly said Ok and maddingly flipped through the pages of my notebook. Thank goodness I took notes the last time we saw her! Although, this baby reacts differently every time so what worked to feed her one time won't necessarily work the next time, making her even tougher to work with. I guess if you go by the "Principles of Motor Learning", it's good to start with the harder stuff. Hah... so i tell myself.

She asks me what I wanted to give her and what kind of nipple. Notes said we were going to start trying thin on her, and we used a standard nipple, so I went with that. ::phew:: L agreed.

This was occuring more frequently lately, I noticed, but I have been feeling like I'm being put on the spot more often. She's really a great person, but maybe it's her pregnancy making her scarier to work with. Or in reality, maybe as time goes on, she expects me to have picked up on stuff and demonstrate that I know stuff before I can do more hands-on stuff. For details on how I fed her and what happened (because i find infant feeding fascinating and want to share this new knowledge :-) ) see the bottom of this post.

This week, I got to feed her again, and it went much better! I was calmer and more confident. I started with the same stuff and techniques, but she was still spilling out of her mouth. L then took her and showed me how to do the pacing I was trying, and then I took her back. Everything was much better!!! I asked her what was so interesting to her left where she kept looking, but L said it's not that it's interesting on that side, but she's trying to decrease the amount of input she's getting so she can concentrate on feeding. Cool, huh? Anyway, L said I did well. :-)

This Tuesday I also got to try feeding a different baby in a sidelying position. It's supposed to be more natural (like when breastfeeding), allowing gravity to help protect the airway, and typically for younger infants, like preterm. This baby was also difficult, but very good to practice with. If I weren't sick, I wonder if I would be allowed to try more today.

... Outpatient ...

Of her caseload of 9 kids on Wednesdays and Fridays, I've seen two kids totally on my own (well, she's always in the room because it's also her office, and plus I have to be supervised). The rest I generally do 3-4 activities within the hour. I do less when the parent is in the room, because the parents are usually hesitant to allow students to do the therapy. Her written feedback is usually full of positive things and almost always only one thing to change, which she tells me in person directly afterward anyway. It's stuff like "try not to add too much of an 'uhh' to the /g/ sound when modeling (this is hard to do)" or "more visual cues (body mveoment/signs)".
I was happy yesterday after I did my part with this adorable little boy who just turned 3 (Huge brown eyes and lashes that extend past the brow-line and even curls up!!!) because afterward, D said "I can't think of anything that I would change about it. It was perfect!" and on the written feedback, she put a big smily face (Sally J, anyone??) and "Perfect!" and nothing else. haha it was great. I said "I should be sick more often" (b/c she wanted me to go home that morning but I said I could stick it out.)

Oh yeah, we had an eval yesterday, too. I did the history portion, which D said I did well with as well, said it was natural and good transitions. Hehe I didn't think I was so good, but doesn't matter what I think! I think D is just a great sweet kind person. That's what I think. :-) I also gave him the GFTA because I still need 3.25 hours in child speech evals.

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It's now 6:00 (I started at 3:30, stopping intermittently), my fingers and toes are freezing, and it still smells like burn. #*$&#!@^

Plus, I'm afraid to use the microwave to cook dinner. Grrr....
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How I learned to feed a baby:

The nurse had her swaddled already, and she brought her to me; I was so nervous! I held her shoulders & head with my left hand as her bottom rested on my lap; I had her facing me so I can watch her as I fed with my right hand (this position called "en face"). I stroked her lips with an empty nipple and let her open her mouth to accept it (rooting). Gave a little pressure with the nipple on her palate (sensory input) and rocked forward/backward (anterior-posterior rocking, for rhythm) to help her start the sucking pattern. I also tried to keep a little pressure on her front chest with my right hand as i held the bottle for deep ventral pressure, which calms her.
Milk spilled out of her mouth with each suck, so I said I thought the milk was coming out too fast for her. L asked me why I thought that, and that was my only reason. She said I was right, but the baby's giving me other signals as well, like arching her back, slight chin tugging, and slight gagging. She also said she needed to be burped for those same signals.

WHOA DERE - I didn't catch all that, and it was obvious to L. Fortunately I guessed the right solution after burping: external pacing. I was horribly inept at that though. With the rocking and all the positioning stuff and watching her signals, I couldn't tilt the bottle so that the nipple emptied without accidentally pulling it out of her mouth entirely, nor could I count her sucks so that I pulled it out more consistently every 5 sucks. L asked me what I wanted to try next, and I said to thicken it to nectar consistency... and as L went to add the crushed rice cereal, I turned the baby in the position I saw her mom try, which was in my left arm. So when L gave the bottle back to me, the baby wasn't taking the nipple anymore - she kept pushing the nipple out of her mouth with her tongue, and not latching at all, just playing with it. L asked me what I wanted to try next, a different nipple or what? Well I took that as a hint (which turned out to be a trick question!) and said let's try an ortho nipple (with a higher flow rate). She still didn't take it, and L finally asked me what I thought was wrong. I said I didn't know. It turns out she was 'disorganized' now because: 1) I put her in a different position, 2) when I rocked, it was side-to-side (lateral) rocking for her, and 3) her arms and legs are no longer in a tightly swaddled position.

WHOA DERE again! Good grief I didn't know it all mattered so much. So we re-swaddled her and I went back to the way I was before, but with the same nipple and thicker milk. It was much better for her. L said I was not bad.

Oy.