Week five marked my return to Ngwelezane hospital and the adult population, with the cases being more interesting by the day.

Week 5 began with hearing, speech and language screening at Thokozani where the old adage ‘you fail to plan, you plan to fail’ was proved true. A particular case in which this was glaringly obvious was having a six year old boy to screen with reported language learning problems. This particular client that was in a monolingual isiZulu school was reported to have difficulties with learning in his mother tongue language which had been the language of instruction. This was particularly worrying for us as clinicians due to his age, language status and patterns of interaction observed by the clinicians. For this client a isiZulu tool was required, making the carrying around of extra forms worth it. The role of the parent in this case was also quiet evident as the presence and concerns stated by Mr U assisted with the process. We were also faced with the question of where to go after using play conditioning and rapport but still being faced with a difficult to test client, in this particular case we realised that no matter how comforting the caregiver is to the child and play and rapport building can make a difference but if the child is still petrified of the screen even with all this support, to simply stop trying to perform the screen. As persisting regardless of evident fear and assent from the child will not only effect the screen but color their upcoming assessments.

Another highlight of the week included a refferal from ward C of a 86 yr old female ( Ms J) that had recently had a stroke, approximately a week prior. Upon arrival the patient was in a passive awake state in supine position. Eliciting a clear response from the patient was not possible and simple commands could not be met. This patient also presented with R side weakness with her tongue being stuck in a lateral position sligthly over the teeth.The merit of reviewing medical information was clearly evident to me in this case as it not only explained her state( due to the recent nature of the CVA) but also findings from the OT that impacted my assessment. Another key skill that this case required was the ability to consult and enquire with nursing staff as they are around her the whole day, having the most knowledge on her progress not just her medical condition. Ms J was a clear candidate for NG feeds requiring intervention immediately as she had not been fed for two or consulted by anyone else who monitered her intake. This proved how important reviewing the medical file is, especially the PO Intake chart for dysphagic patient but also how to make important decisions timeously  to ensure that patients get the care they need as soon as possible. Interaction with other health professionals within the MDT and reviewing their findings and making discipline specific recommendations was highlighted in this case.

Day 4, where it was raining cats and dogs opened our eyes to the logistics within sheduling a day to the clinic. Parents and grandparents had to come by foot or taxi, still encountering rain and had to wait especially long due to the clinic being understaffed. Frustration and tension was highly evident within the community members faces especially since the nurse available had to attend ward emergencies at the same time delaying the process even more. It was also highly evident that regardless of the available clinics and hospitals in the area, residents of the community were still experiencing difficulty with receiving assistance due to there only being two hospitals in the area, a plea from one f the residents being to have more health professionals( speech therapists) within the area when informed about our scope of practice and clients we see. However the common issue of the demarcation of the department of health and education when it comes to servicing school age children for language learning difficulties and school placement for language learning disorders and its related conditions proved to be an issue.

Week 5 opened our eyes to the issues the community faces and how at present government policies and structures do not allow us to adequately service the community

 

Week five marked my return to Ngwelezane hospital and the adult population, with the cases being more interesting by the day.

Week 5 began with hearing, speech and language screening at Thokozani where the old adage ‘you fail to plan, you plan to fail’ was proved true. A particular case in which this was glaringly obvious was having a six year old boy to screen with reported language learning problems. This particular client that was in a monolingual isiZulu school was reported to have difficulties with learning in his mother tongue language which had been the language of instruction. This was particularly worrying for us as clinicians due to his age, language status and patterns of interaction observed by the clinicians. For this client a isiZulu tool was required, making the carrying around of extra forms worth it. The role of the parent in this case was also quiet evident as the presence and concerns stated by Mr U assisted with the process. We were also faced with the question of where to go after using play conditioning and rapport but still being faced with a difficult to test client, in this particular case we realised that no matter how comforting the caregiver is to the child and play and rapport building can make a difference but if the child is still petrified of the screen even with all this support, to simply stop trying to perform the screen. As persisting regardless of evident fear and assent from the child will not only effect the screen but color their upcoming assessments.

Another highlight of the week included a refferal from ward C of a 86 yr old female ( Ms J) that had recently had a stroke, approximately a week prior. Upon arrival the patient was in a passive awake state in supine position. Eliciting a clear response from the patient was not possible and simple commands could not be met. This patient also presented with R side weakness with her tongue being stuck in a lateral position sligthly over the teeth.The merit of reviewing medical information was clearly evident to me in this case as it not only explained her state( due to the recent nature of the CVA) but also findings from the OT that impacted my assessment. Another key skill that this case required was the ability to consult and enquire with nursing staff as they are around her the whole day, having the most knowledge on her progress not just her medical condition. Ms J was a clear candidate for NG feeds requiring intervention immediately as she had not been fed for two or consulted by anyone else who monitered her intake. This proved how important reviewing the medical file is, especially the PO Intake chart for dysphagic patient but also how to make important decisions timeously  to ensure that patients get the care they need as soon as possible. Interaction with other health professionals within the MDT and reviewing their findings and making discipline specific recommendations was highlighted in this case.

Day 4, where it was raining cats and dogs opened our eyes to the logistics within sheduling a day to the clinic. Parents and grandparents had to come by foot or taxi, still encountering rain and had to wait especially long due to the clinic being understaffed. Frustration and tension was highly evident within the community members faces especially since the nurse available had to attend ward emergencies at the same time delaying the process even more. It was also highly evident that regardless of the available clinics and hospitals in the area, residents of the community were still experiencing difficulty with receiving assistance due to there only being two hospitals in the area, a plea from one f the residents being to have more health professionals( speech therapists) within the area when informed about our scope of practice and clients we see. However the common issue of the demarcation of the department of health and education when it comes to servicing school age children for language learning difficulties and school placement for language learning disorders and its related conditions proved to be an issue.

Week 5 opened our eyes to the issues the community faces and how at present government policies and structures do not allow us to adequately service the community

 

Week 4 consisted of a return to Queen Nandi hospital and  visit to Thokozani clinic.

The days at Queen Nandi as always were filled with interesting cases that not only improved my knowledge of speech therapy as a field in practice but also gave me insight into medical conditions, medications  and their impact on speech, language and swallowing.

Day 1 in QNH involved seeing a variety of language disorders across the continuum in terms of severity. The key thing learned and was evident in all the cases was the importance of educational counselling not only for the wellbeing and peace of mind of the caregiver but the best care for the child. Case 1 was a male client who had a past seizure. This client presented as hyperactive and interactive, being able to communicate appropriately to adequately express his needs. In this case a host of sesnory based ASD like characteristics were evident but the clear interactive personality of the client disputed this. The need for boundaries and re-inforcement, stimulation and generalization of current communicative strengths and vocalizations was evident in this case, with progress being coloured majorly by one of the most important MDT members in this case, the caregiver! Potential and a starting point for management was identified but a key area of intervention in this case proved to be counselling, slightly changing the focus of our ‘client ‘ centred intervention .

Another case which proved not only the importance of educational counselling but assessment of strengths and capabilities was case 2 where a 2 year old female was reffered from POPD for suspected delayed milestones in all areas. This soon proved to be  untrue. The client proved to just be an overly coddled little girl that didn’t appear to be at the same level of her peers not as a result of delay or disability but because she wasn’t allowed to be a toddler!One of the dominant themes of childhood development is exploration and learning new things, something this child hadn’t experienced due to not be given opportunity to explore and try independantly. Case 2 communicated predominantly through crying and showed great attachment to her caregiver, as a result of this client 2 didn’t independantly crawl, walk or speak, which upon examination and separation from the caregiver proved to be something she can do but chooses not to when indulged.The caregiver showed great relief but also worry during the examination as she had interpreted the child cries as indications of pain. Counselling was done by the MDT for the caregiver explaining the importance of interaction with other people and children and play and stimulation or the child. General Assessment by doctors and nurses would have immediately allayed these claims by  the caregiver proving that the best source of information and assessment is the client itself.

On the otherside of the spectrum a client and family that requires a great deal of support to place and enforce boundaries for client 3. This client displayed defiant and sometimes agressive behaviour when put in structured situations or situations not in his control. It is in this session that the importance of counselling parents on boundaries to create a structured secure environment was noted. Even more the importance of boundaries within the session was glaring, as these and re-inforcement were neccessary to provide therapy.

Week 4 revealed many and new learning experiences with the most important ones being boundaries and being aware of the caregivers and family’s needs as well as the clients but most of all how the consistency in your  practice as a clinician plays a huge role in progress especially within behaviour management.

 

The long awaited, highly anticipated week had finally arrived. Week three .

Week three began with the usual home-visits where we saw repeat clients within the Niwe and Ngwelezane area. The value and impact of these on members of the community was not fully revealed to me until Monday as community members were grateful and glad to see us but our progress was not visibly evident to me yet. This proved to be a day where Mr and Mrs X dared to hope for more for Mr X, seeing  possibilities and strengths in Mr X that will make a difference in both their lives. It is this renewed hope and room for progress that showed me the value and change this can bring to our patients lives, especially within the community context where there aren’t easily accessible services and the focus on rehabilitation within a functional community framework is not highly probable.  This hope in Mr and Mrs X was ignited by Mr X successfully saying his name by the end of the session. The disbelief and joy in the caregiver and patients eye at this feat proved to all present that there are still possibilities and areas that are a strength not just weaknesses. This was important for us to witness as therapists as it not only revealed to us the emotional state of the caregiver and client and how they viewed their ability after the stroke but also the affect of these attitudes and thoughts on therapy and their investment and trust in the process. This event proved how motivation and hope have a big role to play in rehabilitation and how one aim can open up a persons world again, or get them closer.

The day of the IDDSSI project proved again how working together as a team not only makes things work but how observing and using areas of strength in group members gets the job done well.The most important lesson we all learnt as a team was confidence. Not only in our selves as professionals but as people first, a team then in our areas of expertise. It is this that encouraged interaction between CCG’s and demonstrators and helped us reach our goal to inform and teach. It is this confidence we had in each other that made things transition and run smoothly with everyone being on the same page without having to constantly consult and communicate during the event.

This eventful week ended with my visit to QNH, a truly rich experience. The QNH experience not only exposed us to new conditions and interesting cases but also showed us much you as a therapist colour the situation. Observing Lillian with patients but most importantly the mothers and families showed us what family centered intervention truly looks like and how as a therapist it is not your expectations and goals that matter but those of the child and family. The natural and completely holistic way in which she assessed and treated each client resulted in progress and a successful session every time. The focus was not on the targets but on the mother and child. And it is this that translated into therapy, pushing past the expected goals venturing into bigger domains. The focus on the families needs not only motivated the families to heed her suggestions and follow up with home progammes etc  but also created a real relationship and space where clients flourished.

Week three proved to be one of many lessons and successes, but the greatest lesson being becoming a therapist that builds true relationships with clients and their families to not only ensure success within therapy but encourage practice as a true clinician and not a technician.

 

 

 

 

 

Again the constant theme of challenge continues with the wealth of information and experiences never ending.

Week 2 Began with a day at the community, involving long walks through Nwelezane and Niwe and running away from sly dogs.Here we began with our first patient, a male estimated to being between the ages of 96-99 who had forgotten his name due to being reffered to as mkhulu or approximately half a century. This case again not only showed us how important relationships are within the community in terms of a way to keep track of people and collect case history data if the family is not present but also not to overly pathologise people. Upon arrival we were already forming hypotheses and collating symptoms to best provide assessment and treatment. However the symptoms we had observed such as signs of confusion, hearing difficulties  and not being orientated to self weren’t associated to the CVA that occured years earlier but due to the clients advancing age.

A contrast to this case being Mr X, A hospital inpatient that revealed to me how attention to detail and observation can make huge difference in the patients prognosis and the rehabilitation process. Mr X had 2 CVA’s with infarcts on each side of the brain resulting in paresis on both sides, which is more severe on left. Mr X had been making steady progress but rapidly deteriorated from Monday afternoon to Tuesday morning. The rapid change confused not only me but all medical staff as there wern’t any signs of a regression caused by a medical event. The answer we had been looking for was in the P/O intake chart-Mr X was recommended to be on a soft diet but had been given a full ward diet in the incorrect feeding position for 3 days, requiring a suction before any further reassessment or treatment. Mr X was then seen the next day and presented as well as he initially was before Monday.This taught me and the members of the MDT the importance of not only noting each others recommndations but trusting and following through with them. This further showed me the importance of being critical in investigating( weighing options and choosing the most realistic causes) but to also look at the details and stick to decisions based on my clinical judgement without being highly influenced by team members at the expense of my patients. This event proved to be the day that I realised that to be an effective and good clinician, I have to trust and fully stand by my decisions.

 

The CBR experience has asked for a view of my role and my clients using a different pair of eyes, a different lens.An introduction to the caseload at Ngwelezane hospital made me expect the usual; systematic screening,assessment and treatment of communication disorders utilizing pre-existing knowledge and frameworks.

I was soon proven wrong.

Day 1 involved me getting my first neuro patient, a daunting experience indeed.This however was particularly daunting due to the diagnosis of global aphasia, the ‘worst’ of the aphasia’s in terms of severity. What I was met with, a supportive family invested in the termination of more hospital visits and an elderly male who required assistance wit communicaton, in this case, receptive language at word level.Mr M proved to be hard working and motivated patient, eventhough motivation was for the session to end.

He managed to surpass goals set by my co-clinician and I.This experience proved to us how a close family network and motivation affect progress but also how we can somehow limit our clients capabilities,placing the bar low in some instances standing in the way of their progress. Day 1 proved to be the day where i realised how much my expectations can affect my clients progress and how I have to be ever flexible to truly transition to where the client is not where I think he is at.As in real life you don’t get cookie cutter patients with the strengths and at the level you expect them to be.

Day 3, our day in the community was a sweltering but certainly rewarding one. This setting required even more from us as we had to see a patient without anything to go on.Or so we believed. The home visits not only required us to be confident in our ability to connect and communicate not as ‘professionals’ but people first.This was the first time that we truly got a picture of what our role is in the community setting and what advocacy, prevention and promotion really look like, We were required to liase with the CCG’s and truly work in MDT setting where we might have had different roles and assessments but worked together in the rehabilitation process. It was when we realised this that we were able to service our clients effectively and efficiently. A range of difficulties was seen but the most important role we appeared to play was one of an educational counseller and supporting families as the CVA’s affected not only their family members lives but theirs as well.In general the community setting has constantly challenged my thinking as a clinician, the experience different, exposing me to a wide world i might not have seen with my old eyes.

Thanks for joining me!

Good company in a journey makes the way seem shorter. — Izaak Walton