For Aspiring Singers, Ignorance Is Never Bliss!

Jan_Bickel Bickel_VT2E

By Jan E. Bickel, DMA, author of Vocal Technique: A Physiologic Approach, Second Edition

Singers must understand how to maintain their vocal and overall health in order to keep vocal production at the high levels required of them. In order to achieve this understanding, singers need in-depth knowledge of the anatomic and physiologic function of the complete vocal instrument, a pedagogically well-trained voice teacher, and the knowledge that they can reach out to a team of voice professionals (voice teacher, otolaryngologist, speech-language pathologist, and possibly others) who understand vocal technique and pedagogy as well as voice science and medicine. It is particularly important for aspiring singers to know they have a professional team ready and appropriately trained to help when vocal difficulties arise. The aspiring singer’s trust in this team of professionals must be established at the earliest levels of vocal training. If an aspiring singer is afraid to seek help from the voice teacher, otolaryngologist, and/or speech-language pathologist, valuable time will be lost in vocal development, damage to the vocal instrument may occur, and the aspiring singer may decide to choose another career path. It is imperative that speech-language pathologists and otolaryngologists have some training in vocal pedagogy if they wish to accept singers or aspiring singers as clients, and that voice teachers have a functional understanding of voice medicine and voice science. Ignorance is the quickest path to voice disorders for the aspiring singer.

I wrote Vocal Technique – A Physiologic Approach with the intention of appropriately educating and providing a strong foundation for aspiring undergraduate singers, whether their desire was to enjoy singing as amateurs, or perform as professional singers. In my teaching of undergraduate students, I found these young singers frequently able to produce very beautiful vocal sounds, but having little or no knowledge regarding how their vocal instrument functions when speaking and singing. Most of these singers seemed to have no idea what to do or whom to turn to when their voices were not functioning well. In addition to having a clear concept and understanding of the anatomy and physiology of the vocal instrument, they need to understand how to maintain that instrument on a daily basis; i.e. vocal hygiene, breath management, vocal exercises, careful attention to speaking voice production, and determining what might be detrimental to maintaining healthy vocal folds and bodies. I use Vocal Technique – A Physiologic Approach to teach undergraduate voice classes, initial voice lessons, and again in the vocal pedagogy course in the senior year. I find that students who fully understand the information presented within the book progress much more quickly in the voice studio, and I rarely find them in vocal distress.

Excellent singing requires appropriate posture, refined breath management skills, efficient phonation and resonation techniques as well as the ability to articulate in multiple languages without disturbing the vocal production. Professional classical singing requires perfect phonation; i.e. a clear and resonant tone quality, the ability to create a variety of tone colors, excellent dynamic control, accurate pitch, and the ability to infuse the vocal tone with many appropriate emotions. This means the aspiring singer must have the discipline and dedication to become a vocal athlete with the creativity and imagination of the best professional actor. Learning to sing well enough to perform for the public requires much more than the average person can even imagine. Singers cannot afford to be ignorant about any aspect of their profession if they are to be successful.

There are issues beyond vocal technique that can cause a very well-trained singer to have difficulty with his or her voice – respiratory infection, acid reflux, allergies, inability to “support” the voice appropriately because of bodily injury or illness, interruption in sleep pattern, stress, aging, dehydration, fatigue, and many more. A singer must know intimately his or her voice and how it functions when healthy so that when it is not functioning normally, he/she is fully aware and comfortable reaching out for support from the appropriate professional. A voice teacher can be of great assistance in many cases, but sometimes a singer needs to see a laryngologist, a speech-language pathologist, or a vocal specialist for proper diagnosis and treatment. The demands of professional singing necessitate excellent health, physical conditioning, and careful use of the speaking voice as well as the singing voice, so the aspiring singer must learn how to maintain his or her instrument early in the learning process.

I posed the following question, among others, to 35 undergraduate and amateur singers participating in a choral ensemble and/or a freshman level voice class: “Do you think singers, in general, are reluctant to see an otolaryngologist (ENT) or a speech-language pathologist (SLP) for problems with their voices? 16 responded “yes,” 18 responded “no,” and one did not answer. Of the 16 who responded that singers are indeed reluctant, three had actually seen an ENT or an SLP for a vocal issue. One singer who said she had not seen an ENT or SLP wrote about having “muscle tension dysphonia,” which would seem to indicate that she actually had seen an ENT or an SLP for diagnosis, but did not want to acknowledge this visit. Another respondent wrote that he had “strain and discomfort when singing,” but had never seen an ENT or SLP. Of the respondents who answered that singers are not reluctant to see an ENT or SLP, only two had seen an ENT or SLP, while eight of the respondents made the following statements regarding their own vocal health: “trouble with speaking voice,” “lost voice completely,” “voice hurts when I sing,” “belting created vocal problems,” “laryngitis due to asthma, allergies and bronchitis,” and “unresolved tinnitus, causing problems with pitch matching.”  It follows that these singers might have been helped by a laryngologist or speech-language pathologist, but chose not to reach out to make an appointment.

When asked why an aspiring singer might be reluctant to see an ENT or SLP, the respondents made the following statements: “Singers think the problem is fixable by themselves,” “Fear of being told that there is irreversible vocal damage,” “It can be seen as embarrassing or you don’t want to admit you have a problem,” “Some singers simply resign themselves to discomfort or stop singing altogether,” “Singers feel they can resolve issues themselves by rest and homeopathic methods,” “They don’t want to admit there’s a problem because of the competitive nature of auditions. . . ,” “Perception is the ENT does not care about solving vocal problems for amateur singers,” “It is hard for a singer to admit there is something wrong with their vocal mechanism,” “Singers assume a referral means the voice is bad/sounds bad.”

When asked the same question, two professional singer/voice teachers responded with these comments: “I feel strongly that singers, myself included, are afraid to hear that something may be wrong. I also think that singing is a very expensive endeavor, and the thought of having to spend more money on doctor visits, or treatments, in addition to the cost of taking lessons, and coachings and paying tuition, or fees for applications and auditions, is daunting,”  “The ENT I saw did not at all quell my fears. He told me that I had polyps (which I later found out was not the case) and suggested that I start coming in once or twice a week to help rebuild my voice. I had such an uneasy, unpleasant feeling about it that I went maybe twice. He did some pathetic vocal warm-ups that didn’t teach me anything and sent me to work with an SLP down the hall. Likewise, those exercises felt silly and I never felt reassured that this was going to make me better in any way.” This singer later went to a laryngologist and an SLP, both specifically trained to work with singers, and the results were entirely different as stated: “He was very kind, performing a gentle procedure to examine my vocal cords. He printed out photos and explained very thoroughly what I was looking at . . . the SLP was very kind as well. Her exercises were thoughtful, helpful and specific. She gave me reasoning behind every one of them. I actually followed through and did them every morning.” This singer went on to complete a Master of Music degree in vocal performance and to sing several opera roles successfully and is now a professional actress. Clearly, appropriate preparation of the otolaryngologist and speech-language pathologist in working with singers is important. There is no place for ignorance in the area of vocal technique and pedagogy for these professionals if they wish to take on singers as clients/patients.

Aspiring singers spend much one on one time with their voice teachers, perfecting their technique, and learning to trust the voice teacher implicitly. This trust is built up over time, and is an essential part of the training of the singer. “Singing teachers are not only music educators, they are also guardians of their students’ voices. An astute teacher does not just help prevent vocal difficulties by providing a student with expert, healthy singing technique; he/she also is often the first person to detect a vocal problem and is usually regarded by the student as the source of all knowledge about anything vocal.” (Heman-Ackah et al., 2008)

 When a vocal issue arises, the voice teacher is usually the first to hear it in the singer’s voice, and the singer naturally trusts the voice teacher to “fix” the problem. When the teacher is unable to help the singer resolve the issue, the student begins to feel uncomfortable, worried, and even desperate. Their thinking follows the path – if my voice teacher can’t “fix” the problem, it can’t be fixed. I find that undergraduate student singers are particularly fearful of a referral to the laryngologist, even when I explain that this doctor is trained to diagnose and help resolve the vocal difficulty, not to criticize or place blame. I find that many singers find the idea of getting “scoped” to be quite frightening, even though I introduce this procedure in the freshman voice class, showing a video of a singer in the process. I want them to understand this is not painful and will help to diagnose the problem. Perhaps more importantly, for the aspiring undergraduate singer there is a clear social stigma attached to visiting a laryngologist, so if the singer does make an appointment, he or she will keep it a secret.

When the laryngologist refers a singer to an SLP, this seems to be even more difficult for the singer to accept. It says to the singer that it is his or her own fault that he/she has a vocal problem. If the SLP is not knowledgeable regarding vocal technique, and works with the singer as if he/she is the same as every other client who comes into the office for voice therapy, I will have a very difficult time convincing my student singer to continue with appointments as advised by the laryngologist. An SLP working with singers MUST have some training in vocal technique and vocal pedagogy and should be willing to work in ways that are familiar to the singer from voice studio work.

If there is a diagnosis of vocal nodules, even though the voice teacher may have suggested this might be the case, it is always a shock to the singer. The singer generally comes back to the studio depressed and feeling as though his or her singing life is over. Frequently, vocal nodules can be removed through careful vocalizing and establishment of healthy speaking and singing technique, but aspiring singers want an instant cure. Many will choose to do surgery, even when the laryngologist says it is not really necessary, so they can put this diagnosis in the past as quickly as possible. The singer does not want to consider the need to do preoperative speech therapy, surgery followed by vocal rest, postoperative speech therapy, and, finally, slowly bringing the voice back to the ability to sing with excellent technique. If the singer continues to speak incorrectly or without support the outcome, even after surgery, will not be good.

So, what I am proposing here is that voice teachers give their aspiring singers an excellent foundation in vocal technique – posture, breath management, phonation, resonation, etc., and carefully teach them about the anatomy and physiology of speaking and singing so they understand the importance of establishing an appropriate speaking pitch, not screaming at the college football game, not speaking over noise at the local club, singing music from the correct voice category, and so many other directives coming from the teacher. Voice teachers should insist that their students see videos such as the ones for which links are provided on the companion website for Vocal Technique – A Physiologic Approach, demonstrating the anatomic function of the larynx, lungs, diaphragm, and surrounding muscles. There are many YouTube videos demonstrating the use of the laryngoscope so that singers will know exactly what to expect when they visit the laryngologist’s office. In addition, voice teachers must coordinate with speech-language pathologists in their universities.

Speech-language pathologists need to understand and be able to demonstrate the diaphragmatic-costal breathing that a singer would use when projecting his/her voice in an opera house without a microphone. SLPs wishing to work with singers don’t need to be professional singers, but they must have a strong understanding of what is required for a singer to produce vocal tones worthy of the concert and opera stage, and it would help greatly for them to have formal training in vocal technique and pedagogy. I think this will change the way they interact with singers, and will certainly help gain the respect of their singer/clients. This should help to improve the communication between the two, and will keep the singer coming back to complete the therapy as prescribed. It will be important for SLPs working with singers to be able to use non-traditional forms of voice therapy that have a solid basis in anatomy and physiology. In order for speech therapy to be successful, the singer must be fully invested in the process, and the process must produce results quickly so the singer can get back to singing within a short period of time.  Because singers have developed higher than normal levels of vocal stamina, and phonation skills, they expect to be treated differently as a client of an SLP. If they are not, they will not comply with prescribed treatment and probably will not complete therapy sessions or exercises at home.

It is equally important for the otolaryngologist to understand vocal technique and pedagogy when accepting a singer as a patient. If the otolaryngologist understands the hesitation and fear that is present when a singer makes an appointment to see him or her, this will help the singer remain calm and accept the diagnostic procedure and the diagnosis and prescribed treatment suggestions. “As vocal athletes, singers require special diagnostic and treatment consideration when voice difficulty develops because they must maintain higher-than-normal levels of phonatory agility, strength, and stamina to repeatedly execute complex laryngeal maneuvers” (Zeitels et al., 2002). It seems best that it is a laryngologist, specialized in the care of disorders of the voice and larynx, who treats a singer, but this is not always possible. When it is not possible, the otolaryngologist must take extra care to understand how the singer thinks and uses the voice.

In addition, there must be open and complete communication among the voice teacher, the speech-language pathologist, the laryngologist, and the singer in distress at all times. As the singer generally has full confidence in his or her voice teacher, but perhaps not as much in the SLP and/or laryngologist, this communication will help the voice teacher to motivate the singer to do the appropriate exercises. If the speech-language pathologist has a good understanding of vocal technique and the mindset of the aspiring singer, this will open the door to communication and success. In this regard, two of the professional singer/voice teacher respondents to my questionnaire stated:

“I have raised concerns about my inability to speak or sing, or concerns about how     medicine will affect my singing voice. I understand that I don’t have a medical degree,   but I do know that my voice is largely responsible for my income, and my emotional       health. Concerns raised by patients should be addressed professionally and respectfully,”

Medical professionals and SLPs should “make sure you know how emotionally      connected we are to our voices. Singing is our life, an echo of our very soul. For our       singing voice to be in turmoil is as scary as telling a runner that they ruptured their          Achilles’ tendon. It’s a very big deal.”

Let’s make sure we all do our part in fully educating aspiring singers to the best of our abilities. Every singer needs to be as educated as possible about the anatomic and physiologic function of the vocal instrument in addition to the many other areas of study. Understanding these concepts fully will allow every singer to seek out an outstanding voice teacher, and will certainly help to remove fear and anxiety about reaching out to the laryngologist, speech-language pathologist, or a voice specialist when vocal problems arise. If the voice teacher, laryngologist, speech-language pathologist, and other voice professionals understand voice science, medicine, technique, and pedagogy to an appropriate extent, and communicate clearly with one another when working with a singer in vocal distress, the outcome will surely be a good one. If we communicate well with one another on a regular basis, we cannot help but replace ignorance with knowledge for our singers, clients, patients, and ourselves.

References:

Heman-Ackah, Y. D., Sataloff, R. T., Hawkshaw, M. J., Corln, V. D. (2008). Finding a voice doctor and voice care team. Journal of Singing, 64 (5), 583–592.

Zeitels, S. M., Hillman, R. E., Desloge, R., Mauri, M., & Doyle, P. (2002). Phonomicrosurgery in singers and performing artists: Treatment outcomes, management theories and future directions. Annals of Otology, Rhinology and Laryngology Supplement, 111(12), 21–40.

 

 

 

Nasal Emission Terminology Should be Evidence Based and Consistent with Physiology and Perceptual-Acoustic Characteristics

Nasal Emission Terminology Should be Evidence Based and Consistent with Physiology and Perceptual-Acoustic Characteristics (1)David J. Zajac, PhD, CCC-SLP, ASHA Fellow

Coauthor of Evaluation and Management of Cleft Lip and Palate: A Developmental Perspective

The term “cleft palate speech” has often been used to refer to hypernasality, nasal air emission, reduced oral air pressure, and compensatory articulations of speakers who exhibit velopharyngeal inadequacy (VPI). Hypernasality is defined as excessive resonance of the nasal cavity during production of vowels and voiced consonants. Nasal air emission refers to the audible escape of air during the production of high-pressure oral consonants, especially voiceless consonants. Reduced oral air pressure is the flip side of nasal air emission. When air escapes through the nose, some oral air pressure is lost. Thus, oral pressure consonantsespecially voiceless ones—may be produced with reduced oral air pressure and perceived as weak or reduced in intensity. Compensatory articulations are maladaptive gestures that are produced at the glottis or in the pharynx as a way to circumvent a faulty velopharyngeal valve. The use of glottal stops to replace oral stops is a classic example of a compensatory articulation. Hypernasality, nasal air emission, and reduced oral air pressure are passive (or obligatory) symptoms of VPI. This means that the symptoms occur as a direct consequence of incomplete velopharyngeal closure. Compensatory articulations, however, are active (or learned) behaviors and may not occur in every individual.

Although obligatory nasal air emission is a core characteristic of VPI, many confusing, overlapping, and inaccurate terms have been used to describe its perceptual manifestation. The literature is replete with terms such as audible nasal air emission, nasal turbulence, nasal rustle, and passive nasal frication. Because the velopharynx and nasal passage are complex anatomical structures— which may be significantly altered due to both congenital defects and surgical interventions associated with cleft lip and palate—the variety of terms used to describe nasal air emission should not be too surprising. Numerous other terms have been used to describe nasal air emission that is part of active (or learned) nasal fricatives and will not be discussed here. The reader is referred to Zajac (2015) for a discussion of active nasal fricatives as an articulatory error. Rather, this article will focus on terminology used to describe passive or obligatory nasal air escape.

A Brief History of Current Terminology

McWilliams, Morris, and Shelton in the first and second editions of Cleft Palate Speech (1984, 1990) described nasal air emission as occurring along a continuum. First, it could be visible but inaudible, detectable only by holding a mirror under the nostrils of a speaker to see fogging as a result of the air emission. In such a case, the nasal airflow is laminar, moving in relatively smooth fashion, and does not become turbulent, or noise producing. Clinically, visible nasal air emission typically occurs in speakers who have adequate but not complete velopharyngeal closure and normal resonance. Although visible nasal air emission should be noted when it occurs in a speaker, there are no treatment implications. Continue reading

The Changing Indications for Cochlear Implantation

Theodore R. McRackan, MD Otology, Neurotology, and Skull Base Surgery

By Ted McRackan, MD, co-editor of Otology, Neurotology, and Skull Base Surgery: Clinical Reference Guide

Cochlear implantation is the gold standard for treatment of severe to profound sensorineural hearing loss. Cochlear implants (CIs) were approved by the Food and Drug Administration (FDA) in 1985 and have been suggested to be the most successful neural prosthesis created to date. Over 300,000 cochlear implants have been performed worldwide, with over 50,000 performed in the past year alone. Cochlear implantation involves a surgical procedure whereby an electrode array is placed in the cochlea of the inner ear, which is organized in a tonotopic fashion with decreasing characteristic frequency along its length. Modern CIs contain between 12 and 22 electrodes, which are spaced with the intention of each electrode stimulating a unique area of the spiral ganglia of the auditory nerve. Cochlear implants work by having an external microphone and an external processor convert an acoustic signal to an electrical signal. It is then sent to a speech processor, which is designed to enhance the signal and reduce noise before sending the information to the spiral ganglion through the CI electrode array.

Cochlear implantation is currently at an exciting time point due to the combination of improving technology and proven outcomes that has led to rapid expansion of its indications. The FDA approved the first single-channel CI electrode for adults in 1984, followed by the multichannel electrode in 1987. Cochlear implants were then approved in 1990 for children older than 2 years, in 1998 for children over 18 months, and ultimately in 2000 for children older than 12 months. There has been a recent push to implant children younger than 12 months due to evidence that children implanted at this age are more likely to catch up to normal-hearing peers at an earlier time point. Three major obstacles have hampered this movement. First, obtaining accurate hearing diagnostic testing in a timely manner can often be difficult in those less than 12 months. Second, there is a slight increased risk of surgical complications due to the low blood volume in this age group. Third, it can be extremely difficult to perform cochlear implant programming in this age group. Nonetheless, the clear benefits of early implantation likely outweigh these risks. Pediatricians, audiologists, and otolaryngologists are encouraged to identify infants with hearing loss as soon as possible for hearing rehabilitation. The earlier this is performed, the earlier children with profound hearing loss can be identified, and the earlier they can be implanted, leading to better CI outcomes.

Use of cochlear implantation in patients with residual hearing has been another area of rapid expansion. It was initially thought that all hearing would be lost with cochlear implantation and that if hearing was preserved, patients would not be able to process electrical and acoustic hearing. However, through the trials of the Cochlear Hybrid electrode and the MED-EL EAS electrode, it appears that both are possible. Through these and other trials, most patients had preserved residual hearing after cochlear implantation. Additionally, these patients showed improved hearing outcomes compared to patients without residual hearing. At the present time, it is not clear whether this preserved hearing is sustainable over time. This is an active area of investigation and will continue to be studied for years. Nevertheless, this technology has greatly expanded the indications for cochlear implantation beyond traditional candidacy.

As discussed above, it was previously thought that individuals would not be able to process combined electrical and acoustic hearing. However, cochlear implantation in patients with residual hearing proved this incorrect. This has led to the more widespread use of CIs in individuals with single-sided deafness. Current standard treatment for single-sided deafness includes devices that essentially ignore the deafened ear. However, with cochlear implantation, hearing can be restored to that ear. This was initially performed in patients with severe tinnitus in the deafened ear but is now being more commonly performed in the absence of tinnitus. Further work is certainly needed to develop a more comprehensive understanding of cochlear implantation in this population, but preliminary data show decreased head shadow effect and improvement in binaural summation, spatial release from masking, and potentially sound localization.

Beyond cochlear implantation, the use of auditory brainstem implants (ABIs) in children is another area of expansion. Although this has been performed in Europe for years, it is only more recently being performed in the non-neurofibromatosis type II population in the United States. Several centers have active clinical trials to perform ABIs in children unlikely to benefit from cochlear implantation due to either absent cochlear nerves or cochlear malformations. This is an unfortunate population as they have limited hearing rehabilitation options. Auditory brainstem implants provide an opportunity for hearing in this population, and the neurotology community is excited to hear the results of these trials.

We have come a long way since Bill House developed the first single-channel CI. As outcomes and technology continue to improve, the indications for cochlear implantation will grow. The audiology and otology communities are eager to see what the future holds for cochlear implantation.

About the Author
Dr. Theodore R. McRackan is an assistant professor of otolaryngology at the Medical University of South Carolina. He received his medical degree from the Medical University of South Carolina and completed his otolaryngology residency at Vanderbilt University. Dr. McRackan then completed his fellowship in neurotology-skull base surgery at the House Ear Clinic. His professional interests include neurotologic outcomes and quality of life research. Dr. McRackan and Derald E. Brackmann, MD co-edited Otology, Neurotology, and Skull Base Surgery, which serves as both a study resource for qualifying exams and a portable clinical reference guide. This text features a concise and approachable outline format, contributions by leaders in the field, and key topics such as anatomy and embryology, hearing loss, cochlear implantation, skull base tumors, vestibular disorders, and pediatric otology. View sample pages and place your order at www.PluralPublishing.com.

ASHA 2015 Preview

The 2015 ASHA Convention starts November 12 in Denver and is shaping up to be one of the largest ever. If you are attending this year’s meeting, please stop by our booth (#804) for the following:

  • Save 20% with free shipping!
  • Connect with experts at one of our Meet the Author sessions (schedule to be announced November 11)
  • Browse our new textbooks and request a review copy for your course
  • Meet with Valerie Johns, Executive Editor, about any ideas for a new book

Attend the session, then buy the book!
We have many new books debuting by authors that are presenting at ASHA 2015 on their book topics.

Session Title: Drawing from Different Settings: A Panel Presentation on School-Based Swallowing & Feeding
Presenter(s):  Emily Homer (presenting author); Lisa Mabry-Price (presenting author); Kim Priola (presenting author); Gayla Lutz (presenting author); Donna Edwards  (presenting author); Lissa Power-deFur (presenting author)
Day: Thursday, November 12, 2015 Time: 10:30 AM – 12:30 PM                                     Book title(s): Management of Swallowing and Feeding Disorders in Schools and Common Core State Standards and the Speech-Language Pathologist: Standards-Based Intervention for Special Populations

Session Title: Assessing the Validity of Remote MAPping for Children With Cochlear Implants
Presenter(s): Emma Rushbrooke (presenting author); Louise Hickson; Belinda Henry; Wendy Arnott
Day: Thursday, November 12, 2015 Time: 11:00 AM – 11:30 AM
Book title(s): Telepractice in Audiology and Evidence-Based Practice in Audiology: Evaluating Interventions for Children and Adults with Hearing Impairment 

Session Title: Trauma & Tinnitus
Presenter(s): Marc Fagelson (presenting author)
Day: Thursday, November 12, 2015 Time: 1:30 PM – 2:30 PM
Book title: Tinnitus: Clinical and Research Perspectives 

Continue reading

Plural books honored as Doody’s Core Titles for 2015

We are thrilled to announce that Doody’s has released its Core Titles in the Health Sciences for 2015 which includes 21 Plural books! Doody’s Core Titles in the Health Sciences 2015 is primarily for medical, nursing, and allied health librarians around the world who are charged with making the book buying decisions for their libraries within budget guidelines. A core title is a book or software title that represents essential knowledge needed by professionals or students in a given discipline and is highly recommended for the collection of a library that serves health sciences specialists.

Core Titles for 2015:

Effective Communication: A New Health Care Obligation

Beukelman Effective Communication Image

By: Sarah W. Blackstone, David R. Beukelman, and Kathryn M. Yorkston
Editors of the new Patient-Provider Communication: Roles for Speech-Language Pathologists and Other Health Care Professionals

Prior to his accident, Frank was a 26-year-old energetic, physically active young adult with a wide range of interests and a full social life. A C3–C4 cervical spine injury left him unable to move his limbs. When medically stabilized, he was transferred to the surgical intensive care unit, where he was ventilator dependent and in halo traction. He was unable to speak and his only intentional gesture was a gaze shift. The hospital communication team helped Frank establish a reliable yes/no response (looking up to indicate “yes” and down for “no”). They encouraged his nurses and family to offer other choices as well (“maybe” or “later” or “I don’t know”). A speech-language pathologist showed him a speech-generating device (SGD), but when initially asked if he wanted to use it to “talk,” he responded by looking down, “No.” Later that same day, the team demonstrated the SGD again, showing him how he could use it to control the TV and a fan. When asked if he would be willing to give it a try, he replied, “Yes!” by looking up. Within 24 hours, Frank was using a template on the SGD to call a nurse, ask for medication, control a fan, and turn the TV off and on, all with a simple serial scan method and a switch. Over time, he became an active participant in his recovery process, asking doctors questions and participating in decisions about his treatment plan.

Effective communication between patients and providers is a core component of patient-centered and value-based health care. According to the Joint Commission (2010, p.1), effective patient provider communication is the successful joint establishment of meaning in which patients and health care providers exchange information, enabling patients to participate actively in their care from admission through discharge, and ensuring that the responsibilities of both patients and providers are understood. To be truly effective, communication requires a two-way process (expressive and receptive) in which messages are negotiated until the information is correctly understood by both parties.

The medical encounters that occur across the continuum of health care are usually time constrained and many are stressful, high-stake interactions. When communication breakdowns occur, the impacts can be devastating for patients, family members, providers, and the health care system. Research shows that communication difficulties are among the major causes of sentinel events and can negatively affect patient outcomes, safety, and satisfaction, as well as result in increased readmission rates, length of stay, and additional health care costs. Because of the diversity of patients and families served in our health care systems, successful communication can be very difficult to achieve. In fact, many patients present with multiple communication vulnerabilities.

At age 4 years, 6 months, Guillermo was in the ICU, intubated and awake following a series of surgeries for tracheoesophageal reconstruction. Guillermo and his family were from Honduras and spoke Spanish only. Guillermo was most relaxed when his mother or eldest brother were sitting next to his bed and rubbing his arm. Although hospital policy supported his family remaining at bedside throughout the day and night, there were moments when they needed to step away for personal care, to attend team meetings along with a translator, or for other reasons. The speech-language pathologist provided Guillermo with a simple voice output aid (Ablenet Little Mack) with messages that included, “Where is my family,” recorded in both Spanish and English, so hospital staff could understand him. The speech-language pathologists also made a 20-target Go Talk+ device (Attainment Company) available to him. It featured 15 target photos of family members with messages such as, “I want mom,” “You’re my best friend, Frederico,” “I love you,” and “Hold my hand,” as well as some medical messages. All messages were recorded in both languages.

We define “communication vulnerability” as the diminished capacity of an individual to speak, hear, understand, read, remember, or write due to factors that are inherent to the individual (e.g., disabilities related to receptive and expressive language skills, hearing, vision, speech, cognition, and memory, as well as language spoken, lifestyle, belief system, and limited health literacy), or related to the context or situation (e.g., a noisy environment, being intubated in an intensive care unit after surgery, suffering injury while traveling in a foreign country, having cultural practices, lifestyles, or religious beliefs that are not understood or accepted by providers).

Eleven-year-old Joshua had a bone marrow transplant. He was acutely aware of his suppressed immune system and created and used several communication tools during the time he required the use of a Bi-PAP noninvasive ventilator. Using a simple voice output communication tool, Joshua insisted on having the following message available at all times: “If anything falls on the floor, use the Sani-wipe to clean it before you let it touch me. Also, if your gloves touch the floor when you pick it up, change your gloves before coming near me.”

In the book, Patient-Provider Communication: Roles for Speech-Language Pathologists and Other Health Care Professions, we describe how health care facilities and the providers who work within them can begin to assume a more active role in supporting patients who are communication vulnerable. Speech-language pathologists, nurses, administrators, and physicians are key to improving the “culture of communication” within their facilities, spearheading interprofessional practices that benefit all patients and ultimately providers and the facility’s bottom line. Currently, the role of communication intermediary is assumed by a few providers or family members with a personal commitment; although a rising number of health care organizations are beginning to specify policies and role assignments regarding the coordination of communication support services, communication facilitation for all patients with communication difficulties (not just those who are deaf or have second language issues), or a legal or medical intermediary designated to ensure that communication vulnerable patients accurately participate in legal and medical decisions.

Examples of promising practices and strategies across health care settings are highlighted in individual chapters that focus on doctor visits, emergency services, Intensive and acute care settings for children and adults, inpatient and outpatient rehabilitation, long-term residential care, and end-of-life care. In this book, we have invited authors who have considerable expertise in patient provider communication services across the range of health care settings to share information about the policies, intervention strategies, communication materials, and technologies that are being implemented within their medical settings to support the needs of communication vulnerable patients.

The wife of a person with ALS described his end-of-life experience: He was having a great deal of difficulty breathing and simply could not get comfortable in his hospital bed or wheelchair. We decided to go with in-hospital hospice since his pain management was not well controlled. In hospice, he regularly used his (eye gaze-accessible) SGD to tell us what he did and did not want. I am so grateful that he was able to use it extensively during the last few days of his life. I do not know what we would have done without it.

The authors recognize that there continues to be a considerable gap between clinical research evidence, what is mandated by health care policy, and what is experienced every day by patients, their families, and providers during medical encounters because of the ways in which many health care organizations currently deliver care. In other words, we recognize that implementation, or the process of putting effective patient-provider communication policies into practice, continues to be a challenge within many health care organizations; however, in the final chapter of Patient-Provider Communication we discuss a number of implementation strategies.

References
The Joint Commission. (2010). Advancing effective communication, cultural competence, and patient and family centered care: A roadmap for hospitals. Oakbrook Terrace, IL: Author.

About the Authors
Sarah W. Blackstone, PhD, CCC-SLP, is president of Augmentative Communication, Inc. She has authored multiple texts in the augmentative and alternative communication field as well as articles in Augmentative Communication News and other publications. David R. Beukelman, PhD, CCC-SLP, is the Barkley Professor of Communication Disorders at the University of Nebraska-Lincoln. He has served as director of research and education for the Communication Disorders Division, Munroe-Meyer Institute for Genetics and Rehabilitation at the University of Nebraska Medical Center. Kathryn M. Yorkston, PhD, BC-ANCDS, is a professor of rehabilitation medicine and head of the speech pathology division within the Department of Rehabilitation Medicine at the University of Washington Medical Center.

Plural Author Blake Wilson Awarded Fritz J. and Dolores H. Russ Prize

Blake WilsonOn January 7, 2015 the National Academy of Engineering announced that the 2015 Fritz J. and Dolores H. Russ Prize would be awarded to Blake S. Wilson, Grame M. Clark, Erwin Hochmair, Ingebord J. Hochmair-Desoyer, and Michael M. Merzench “for engineering cochlear implants that enable the deaf to hear.” The $500,000 biennial award recognizes a bioengineering achievement that significantly improves the human condition.1

“This year’s Russ Prize recipients personify how engineering transforms the health and happiness of people across the globe,” said NAE President C.D. Mote Jr. “The creators of the cochlear implant have improved remarkably the lives of people everywhere who are hearing impaired.”1

Dr. Blake S. Wilson is the Co-Director (with Debara L. Tucci, MD) of the Duke Hearing Center and is an adjunct professor in each of two departments at Duke, Surgery and Electrical Engineering. He also is the chief strategy advisor for MED-EL Medical Electronics GmbH of Innsbruck, Austria, and a Senior Fellow Emeritus of the Research Triangle Institute (RTI) in the Research Triangle Park, NC, USA. He has been involved in the development of the cochlear implant (CI) for the past three decades, and is the inventor of many of the signal processing strategies used with the present-day devices.

Dr. Wilson and the teams he has directed have been recognized with a high number of awards and honors, most notably the 1996 Discover Award for Technological Innovation; the American Otological Society’s President’s Citation in 1997 for Major contributions to the restoration of hearing in profoundly deaf persons (to the RTI team); the 2007 Distinguished Alumnus Award from the Pratt School of Engineering at Duke; the Neel Distinguished Research Lectureship at the 2008 Annual Meeting of the American Academy of Otolaryngology, Head & Neck Surgery; and recently the Lasker-De-Bakey Clinical Medicine Research Award in 2013.

Better Hearing with Cochlear ImplantsDr. Wilson co-authored Plural Publishing book Better Hearing with Cochlear Implants which provides a comprehensive account of a decades-long research effort to improve cochlear implants (CIs). The research was conducted primarily at the Research Triangle Institute (RTI) in North Carolina, USA, and the results provided key pillars in the foundation for the present-day devices.

 

1. National Academy of Engineering. Inventors of Cochlear Implant Win 2015 Fritz J. and Dolores H. Russ Prize [Press Release]. Retrieved from http://www.nae.edu/Projects/MediaRoom/20095/107830/129146.aspx

A Tribute To Marion Downs

As many of you know, Dr. Marion Downs passed away recently. Here we post a nice tribute written by Dr. Jerry Northern that he shared with us.

Dr. Marion Downs Passes Away at Age 100 World-renowned Audiologist and Pioneer for Infant Hearing Screening

Dr. Marion Downs Passes Away at Age 100
World-renowned Audiologist and Pioneer for Infant Hearing Screening

Dr. Marion P. Downs, an innovator in the field of pediatric audiology and a tireless advocate for the early identification of hearing loss, passed away on November 13th, 2014. During her extraordinary career at the University of Colorado Health Sciences Center, Dr. Downs developed and evaluated techniques for testing hearing in babies and young children and for fitting them with hearing aids. Dr. Downs created the first universal infant hearing-screening program in 1963 in Denver, CO. She relentlessly pursued making the identification and management of hearing loss in infants and children an important medical, educational, and public health issue. Her professional publications and lectures brought worldwide attention to the importance of early intervention for hearing loss. Today, in the United States, more than 96% of all infants born in the US receive a newborn hearing screening thanks largely to her efforts. Numerous international countries have followed her lead in establishing universal infant hearing screening programs. Continue reading

Management of Facial Paralysis

By Mark K. Wax, MD

Editor of Facial Paralysis: A Comprehensive Rehabilitative Approach

Facial Paralysis: A Comprehensive Rehabilitative Approach

Facial Paralysis: A Comprehensive Rehabilitative Approach

Facial paralysis is a devastating process. Normal facial function is of paramount importance in both cosmesis and how individuals are perceived by others. It also plays a role in natural physiological processes. When the facial nerve—which provides animation to the muscles of the face—is paralyzed, there are severe cosmetic, psychological, as well as physiologic sequelae. The facial plastic surgeon has the ability to play a unique role in both the reconstruction and the rehabilitation of the adverse effects of facial paralysis. Management paradigms for the multitude of issues that face these patients involve a team approach—not only facial plastic surgeons, but also speech pathologists, physiotherapists, social workers, family, and so forth. The facial plastic surgeon stands at the epicenter, able to direct the care of the patient to these different specialists. Continue reading

Are Duty Hour Restrictions Making Residents Feel Better or Worse?

By Evan J. Propst, MD, MSc, FRCSC co-author of Airway Reconstruction Surgical Dissection Manual

In 2003, the Accreditation Council for Graduate Medical Education (ACGME) mandated an 80 hour work week limit for residents. In 2011, this same body mandated a 16 hour shift limit for first year residents. Both of these mandates were introduced to reduce resident fatigue with an eye towards improving patient safety, resident education and resident wellbeing. These regulations are enforced throughout the US and institutions can be fined if residents are found to be working beyond these duty hour restrictions. Continue reading