Invasive exam helps patients get back on solid food
By Malka Eisenberg
Issue of November 6, 2009/ 19 Cheshvan 5770
Michaelle Gorman screens all new admissions at Woodmere Rehabilitation and Health Care Center, evaluating and treating for speech, language and swallowing disorders. But of all her efforts as a speech pathologist there, her greatest triumph, she said, is helping patients learn to eat again.
“When you can help people with hearing losses, that’s a wonderful thing,” she explained. “When you work with people for clarity of speech, when people have a stroke and you restore language function or the ability to communicate, it’s very gratifying, but when a patient has been on tube feed for a while and then you get them able to taste food and eat again — there is nothing like that! When I see it I say ‘hurray!’”
Gorman, who has a Masters of Science degree and a certificate of clinical competence in audiology and speech language pathology, has been a speech pathologist since 1986 and at Woodmere Rehab since 2001. She also trained at Columbia University College of Physicians and Surgeons with Dr. Jonathan Aviv, who developed an exam called FEESST, or Flexible Endoscopic Evaluation of Swallowing with Sensory Testing. Woodmere Rehab bought the equipment about two years after she began work there.
FEESST uses a thin flexible tube with a camera that is threaded through the nose and throat to see the entire swallowing area, said Gorman. It enables her to see “all the anatomical portions of the area and assess the integrity and sensitivity of the area.” That, she said, is a “predictor of aspiration — food going down the wrong pipe — to make sure the food goes to the esophagus and not the trachea to the lungs.”
“We see exactly where the problem is to try to fix the problem, but we can’t always fix it,” she said. They test the patient’s ability to manage different consistencies of food — pureed, solid, very soft solid — and different densities of liquid. “Someone may have trouble with thin liquids,” she noted, “but have an easier time with a more viscous, slightly thicker liquid.”
Patients are placed in different positions to be able to swallow, she said. For example, for a patient who has suffered a stroke on one side, a unilateral cerebral vascular accident (CVA), “Sometimes we do head positioning to the affected side to enable the patient to swallow,” she said. “We are only able to see that once we are in there.”
“The patients have to be able to tolerate it,” she stressed. “It’s not the most comfortable. I do it speedily. I do it where the patients know you; they trust you a little bit. It takes about ten minutes, sometimes a little bit more.”
A patient from a hospital in New York City was not assessed for swallowing before arriving at Woodmere Rehab since that hospital would not test unless the patient is off the ventilator for 24-48 hours. “After about a week in Woodmere Rehab, if the pulmonologist says that the patient is stable, even if they’re on a ventilator or have a tracheotomy, if it’s deemed safe,” they test. “We have a lot of success,” she added. Unconscious or sedated patients cannot be tested with FEESST, but even patients who are not alert receive an “eating by mouth test; the goal is to get them eating.”
Gorman has done hundreds of FEESST exams in ENT (ear, nose and throat) offices, at South Nassau Communities Hospital and at Woodmere Rehab, where there is a full time speech therapist in addition to Gorman, who is there “almost” full time. “A lot of patients come because of that,” she said. “I’m there, the equipment’s there, it gets done. I have an ENT come in and confirm what I’ve done. We manage to cover all bases.”
FEESST can be done in the speech therapist’s office or by the patient’s bedside and a respiratory therapist is on hand when tracheotomy or ventilator patients are tested.
One patient with neurological deterioration from Guillaume-Barre syndrome couldn’t talk when he entered Woodmere Rehab. “He couldn’t move his mouth to smile,” she said, but by the time he was discharged, after therapy, he left talking, swallowing, eating and joking. “When we have successes it’s a professional high,” she said. “There’s nothing like it. When you improve the quality of life for them and for their family, it’s awesome.”
