Speech-Language Pathology (SLP) student Claire Halberstadt ’18 remembers first looking at an X-ray image’s indecipherable haze of black, white and various shades of gray, and thinking, “What am I looking at?” Now after a semester in Randy Dubin’s, MA, CCC-SLP, class, she can not only confidently identify various structures of the throat used in swallowing, but also recommend treatment plans for those with swallowing disorders, clinically known as dysphagia.
“A modified barium swallow study is basically a dynamic X-ray that is taken while a patient eats or drinks a substance called barium to assess swallowing,” Halberstadt said. “With time and lots of practice, you become a pro at identifying the different structures of the larynx and pharynx, interpreting whether a swallow study is disordered and understanding what treatments might be appropriate given the physiology of a swallow.”
Dysphagia is one of the nine specific practice areas SLPs are required to be knowledgeable about in their profession, according to Kathleen Youse, Salus SLP program director. She explained swallowing is an intricate bodily function that involves hundreds of muscles and finite muscular coordination. For most, swallowing is an automatic process, but when it is not, it can cause serious complications.
“We take swallowing for granted when healthy, but if swallowing is impaired as a result of a disability or illness, it can lead to serious complications,” she said. “When the swallowing mechanism does not work as intended, the person is at risk of aspirating food or liquid, including saliva, into the lungs and this can lead to aspiration pneumonia. If left untreated, this can become a life threatening illness.”
There is an array of direct and indirect therapy techniques SLPs can recommend, according to Rachael Borman ’18SLP, one of the students in Dubin’s class.
“We learned about the various maneuvers, diet modifications and exercises we can recommend to clients, depending on different issues that may be present during the course of the swallow,” she said.
As a professor, Dubin brings a wealth of real-life experience to the classroom. He has worked in both acute care and rehabilitation settings for nearly 20 years, and is a specialist in dysphagia across ages - for children and adults. In addition to teaching at Salus, he is the speech pathology team leader at the Hospital of the University of Pennsylvania, where he manages nearly 30 SLPs. In his Salus course, Dubin strives to ensure his students are well-rounded in various aspects of dysphagia and always takes the opportunity to add real-world experiences into his lectures whenever possible.
“I focus a lot on evidence-based practice,” he said. “I add a lot of information about what they would expect to see when they get in the field so they have an idea about what to expect before taking an externship.”
During the semester, students were split into small groups to observe SLPs at work in one of three hospitals: the Hospital of the University of Pennsylvania, Penn Presbyterian or Pennsylvania Hospital.
The students observed clinical bedside swallowing evaluations and learned about performing tests such as instrumental assessments and videofluoroscopic swallow studies.
Borman believes this unique observation experience helped her further understand the concepts she was learning about in the classroom.
“The clinical observations at the hospitals allowed us to take the information we have been learning in class and apply it to real life scenarios,” she said. “It was really gratifying to hear concepts and terms that were discussed in class in these settings, and to be able to understand what was being discussed.”
During another off-campus experience at Penn Medicine Rittenhouse, students learned about endoscopic swallowing evaluations. An SLP inserts a fiber optic cable through the nasal cavity and down into the back of the throat to view and analyze the movement of various structures necessary in swallowing on a computer screen. Students then had the opportunity to practice the procedure on a plastic model. They also tasted different flavors and consistencies of thickened liquids to get a better idea of what patients experience when put on a modified consistency diet, which includes foods and beverages that are physically altered so they are more manageable to swallow. Examples include chopping or mashing food into smaller pieces, moistening dry foods and adding thickener to beverages.
Interprofessional training is another important aspect of Dubin’s dysphagia course. He and Andrea Carr Tyszka, MS, OTR/L, SIPT, assistant professor in the University’s Occupational Therapy (OT) program, conducted a combined class of SLP and OT students. Dubin’s colleagues at the Hospital of the University of Pennsylvania who specialize in pediatric feeding and work within the neonatal intensive care unit provided specialized lectures. One of the guest lecturers even brought her newborn baby to create a more interactive presentation. During the lesson, students reviewed how the two professions would collaborate in the care of infants with feeding/swallowing conditions.
“This was a great opportunity to bring both programs together to discuss issues, strategies and how to manage clients jointly,” he said.
The students were broken up into small group and challenged to come up with solutions for various case study problems.
“OTs are the experts when it comes to adaptive equipment and making modifications to enable safe, positive experiences with feeding, both for infants and mothers who are breastfeeding,” Halberstadt said. “It was eye opening to share our perspectives with one another, using a collaborative, interprofessional approach to come up with solutions for fictional patients.”
Borman agrees, saying the experience allowed each discipline to have a better understanding of one another and how they can work together in their future professional careers.
An emphasis on ethics was also incorporated into the course. Dubin discussed topics SLPs may encounter when treating a patient with dysphagia such as quality of life for patients with dementia, feeding tubes to sustain life and resuscitation.
“Randy encouraged us to integrate our clinical knowledge about swallowing with the difficult ethical situations we will face,” Halberstadt said. “As future SLPs, we will play an important role as part of a larger medical team, ensuring that the patient’s and family’s choices with regard to personal and religious beliefs are respected and upheld.”
Dubin hopes his students leave class with a well-rounded knowledge or understanding of the various intricacies that accompany swallowing disorders. As a faculty member who has been present since the program was launched in 2015, he believes the University’s SLP program provides students with both the conceptual and practical knowledge needed to succeed as professionals upon graduation.
“Overall, the SLP program is very well-focused on good education and clinical opportunities for students,” he said. “That’s what I came on board to help with and have enjoyed the mission and vision that was originally created.”
