FEES Test: Behind the Endoscope

          Over this past semester, I have seen many cerebrovascular accident patients. It is heart wrenching to see how both patient and family are impacted by this event; especially because of its unpredictable nature. A common link between all of them is a loss of one or more functions. Dysphagia is a dangerous result, and occurs in almost 65% of stroke patients.  A main complication is aspiration of food or fluids, which in turn can cause acute airway obstruction, pneumonia, and impaired lung function.

           There is a diagnostic test that helps decrease risk of complications related to dysphagia, resulting in an increase in quality of life. This test is referred to as a 'FEES': Fiberoptic Endoscopic Evaluation of Swallow. I have had the pleasure of not only watching this test be performed, but also assisting. It is interesting to see all of the components of this evaluation because swallowing is a function that is not appreciated enough. 

          The procedure/evaluation is usually ordered by a physician. This can be related to diagnosis or physical manifestations. An initial assessment is done and then the procedure starts. The patient bravely allows a tiny camera (Fiberoptic Endoscope) to enter through one nostril. As they swallow, the endoscope is positioned in the oropharynx. Then, different consistencies of food containing green dye are ingested. Ingestion provides information pertaining to how food is handled. They can view if there is residue present or if aspiration occurs. Once complete, a diet specific to capabilities is prescribed. This can range from regular to soft mechanical to pureed food with thickened liquids.

          To provide quality results, there is an extensive process of documenting. There are three aspects to this documentation, which as a whole paint the entire picture. First, there is anatomic and physiologic assessment that provides a checklist of parameters to evaluate coordination, speed, and sensory testing. Second, there is a physical observation of swallowing. This is the 'interesting' part because you get to directly view the process of swallowing in an individual, in real time. The final aspect provides documentation of therapeutic strategies that were attempted as well as the success rate. A recommendation is provided upon these findings.
         After implementing this new method of documentation and examination, total time and completeness were evaluated for each examiner. Each portion of the exam was timed as well as the total time for the whole evaluation; almost every portion of the time they looked at was significant with respect to the effectiveness of the examiners. The interpretation time was the only aspect not statistically significant, meaning that there was no difference observed between the examiners, meaning their knowledge and how they interpreted what they saw was the same. However, report completeness, documentation time, and the evaluation system were all significant! This means overall the entire system of documentation in this FEES testing really did reduce the time considerable and each report was finished to a higher level of completeness. Time was decreased by more than 35%, completeness increased from 39% to 70%, and while the interpretation time increased a little, it was not statistically significant. This essentially means that it could have been coincidence. While the study size could have been larger, and those specializing in swallowing disorder is limited, this study was still beneficial to see a higher documentation standard. When put into practice, is statistically significant in the patient care received by nurses and doctors.
              Overall, there are many factors that contribute to the swallowing process I was unaware of. I am glad that this test is available and performed in a specific way to provide safety for patients. 

To view an in depth look at the documentation process and application of this test, visit:

Saving Time and Ensuring Proper Application of FEES

Stan the Man

1. During a group effort at iStan simulation, we all were able to perform tasks to help our patient. Some were successful, and some were not. However, all were a great learning experience. I completed the following:
- I was able to perform the Head to Toe assessment. I enjoyed this process because I did not perform the assessment during my first experience with simulation. To examine a simulation 'person' was pretty cool! To feel pulses, hear lung, heart and bowel sounds, and interacting was different from an actual person. However, it felt awesome to be confident with this skill. This is because I know I have practiced on REAL LIVE people!!
- I was able to use the medication dispenser for the first time. This was exciting because I have watched the instructors do this during clinical, never on my own. I felt like this was a beneficial for me since I usually learn by doing things on my own.
- Along the same 'vein' of medication, I hung my first bag of antibiotics that were not IV piggyback. I was told that I did 'not necessarily' do it wrong, but there is a better technique to performing this task. I am glad to have learned this because I have no come across this before. When the time comes, I will have a better idea of what to do.
- I also drew blood for labs. This was an activity I have never attempted and it was slightly intimidating. After completing the draws, I felt less nervous about the process.

2. While in simulation, I definitely learned that it is ok to ask for help. While assessing Stan, I was unsure as to what I heard for bowel sounds. I was able to ask my team member to listen and offer a second opinion. It is always better to confirm information, rather than continue with inaccurate data. I also had to call the 'Lab' to confirm labeling of samples, whether blood, urine or a wound culture. This taught me to be aware of policy differences in order to achieve tasks at hand. When anything is incorrect with sampling, they are typically thrown away. This provides more stress to the patient and breaks the relationship that has been established through trust.

3. It is difficult to say what will be done differently for the next simulation experience. This is partly due to the many different situations that I may have not encountered yet. However, I will be more conscious about obtaining 'Hospital Policy'. It felt awful to break the trust with my patient by having to redraw labs, causing him more pain. Putting myself in that situation, I definitely would feel nervous as to the care I was receiving if something like this happened. I will also strive to work better as a team and ask for help. I am also embarrassed with my uniform discrepancy. The tattoo located on my wrist was partially visible as well as on my chest. I am proud of my school and fellow students, emitting a message that is negative about either is the last thing I want to do. Therefore, even if my uniform covers these markings, I will perform extra measures to prevent an accidental show. I am glad that this happened during simulation, and did not emit this negative image to actual patients.

4. Watching our peers is always helpful, especially because we all are 'in the same boat' so to speak.
- I learned that empathy is huge! A patient is not a task! I learned that even though we do specific tasks involving the patient, they are still the most important feature of our care. By seeing this, I put myself in the patients shoes. I know I would not feel important or cared for.
- I learned that patient teaching is much easier than it seems. One of the participating members did an excellent job of making conversation with Stan. They seamlessly segued into teaching without a blink of an eye! It was appropriate in content and timing. It also did not inflict feelings of inadequacy on the patient. This method and attitude conveyed a sense of better compliance with the patient. It also helped show Stan that this individual cared and established a relationship quickly.
- I learned that spirituality is usually ignored. Again, I was beyond impressed with the other group because one individual remembered to ask if the patient would like to pray before their meal. It was beautiful to see such a thoughtful offering.

5. During our simulation experience I tried to utilize information learned from the classroom, no matter how small.
- I utilized my knowledge of edema and inflammation to provide patient specific care. I provided elevation to afflicted extremity. I was also able to provide a specific assessment of pain.
- I also put safety into action, concerning medication administration. While at the medication dispenser, I performed two checks and the third at the bedside. This was done by confirming patient, medication, allergies, route, dosage, and confirmed timing. Timing was confirmed in the chart to make sure that prn drugs were not given too early, which was important since they were pain medications.
- Another thing put into practice was importance of making and maintaining relationships with patients. Everything we do has consequences; it is ideal that they are good.

Overall, I felt the day was full of learning and new experiences. I feel more confident with my care of patients

Keep that positive attitude flowing!

Alzheimer's Walk

This morning was an amazing opportunity to see the community come together for an awesome cause! Our class helped set up and encourage other volunteers. Check it out and donate!

http://act.alz.org/site/TR/Walk2016/AL-AlabamaFloridaPanhandle?pg=entry&fr_id=8816