An Interview with Stefanie Haft
Unmasking Rehab Medicine During COVID - Narratives & Portraits
Stefanie is a speech language pathologist at Mount Sinai in NYC. She first learned of speech language pathology from doing a career survey in high school, and then shadowed her next-door neighbor, who was a school-based speech language pathologist (SLP). She also observed a hospital-based SLP and enjoyed the idea of helping people talk and eat. “I always felt like I would work with kids with autism or special needs,” said Stefanie, but then in her last semester in grad school she was placed at a hospital and ended up really liking it and decided to work and do her clinical fellowship there. She now works as a SLP in NYC, working mostly with patients with spinal cord injury in the rehab department, where she’s been for the past four years.
Stefanie said she loves working out and being part of a gym and so at the start of the pandemic it was hard not having that community. Despite the challenges, on her off-days from working with COVID patients she would work out as much as possible and said that this routine kept her grounded. “It was pretty isolating at the beginning, I didn’t think it was safe to see family or friends, and so my co-workers really became the only people I really interacted with in person. We became a tighter group during this because we were just always around each other more than anybody. It’s interesting being part of a frontline community and frontline population [in NYC] which is kind of cool but also... did I choose the right career? Do I really want to be frontline? But I think it’s really been rewarding” said Stefanie. During Passover this past April, her parents dropped off food for the holiday to her and her sister. “Normally we would have all been together but we couldn’t... we thought it would be best to do it over Zoom.” Though more recently, she’s been able to see her parents socially distanced outside in their backyard. In addition, Stefanie is part of a COVID study and so she said it’s comforting knowing her status, as she gets tested for the virus every week.
Before COVID, Stefanie worked as a rehab therapist three days a week and as an outpatient therapist two days a week. After the pandemic hit NYC, her and her colleagues were assigned full-time to acute care at the main hospital. In addition, because they had to close the acute rehab unit, she was tasked with off-loading her pre-existing patients. “It was really devastating to a lot of people because we were sending patients home knowing that they weren’t going to get care for so long, but they weren’t ready to leave.” In terms of logistics, “we were frantically planning how these people were going to get home, making sure every patient had a safe disposition, and then taking on a new job over the weekend.” During this hectic time, Stefanie also noted that her colleagues were getting sick and so on top of everything they were short-staffed. “We didn’t know what we were in for.” Their wardrobe also changed, from business casual to hospital scrubs. Another major change for speech pathologists like Stefanie was that certain imaging procedures, like the fiberoptic endoscopic examination of swallowing (FEES) and the modified barium swallow, became increasingly risky to the health care professionals to perform. “It’s basically like... you wouldn’t do surgery on someone if you didn’t having imaging, you wouldn’t diagnose a stroke unless you imaged it. And so for the swallow, we don’t actually know what’s happening [unless] we image it. That was completely taken away from us, and it was our biggest challenge.” Initially Stefanie said that they pushed to keep imaging. However, as they learned about ENTs who had gotten really sick with COVID after doing these procedures on COVID-positive patients in China and Europe, they realized stopping imaging was the right call. Without their ability to image, Stefanie said “we had to go back to the bare bones of clinical intuition, ask for extra chest x-rays, and just really be cautious.”
With guidelines constantly changing Stefanie and her team were always trying to figure how to safely treat patients and protect themselves: “All of a sudden we got a consult for a trached patient who was COVID positive, and so we had to decide really fast, are we safe seeing this patient? What’s our risk and how are we going to manage them? Because the statistics on patients who are trached is that a high percentage of them will aspirate, and 70% of those who aspirate, aspirate silently. From being on her previous rehab unit, Stefanie had significant experience working with patients with tracheostomies, and so these skills became vital in her work with COVID patients. In addition to the immediate speech team, she also said they consulted with physicians, respiratory therapists, and nurses, all working together to answer the question, “How do we manage a disease we’ve never seen? What does that look like?” At her work, they were given extra days off which Stefanie said was so important because “the work was absolutely exhausting.”
There were a couple patients that really stood out to Stefanie. One patient who was COVID-positive was improving but then suddenly needed to be re-intubated and had a tracheostomy placed. Stefanie met him after being weaned from his ventilator. “I went in and gave him a speech eval and found out that he was actually a respiratory therapist from another hospital.” He was able to have regular food and liquids, and the team helped him with his speaking valve, downsizing his tracheostomy and getting him decanulated. A couple weeks after rehab, Stefanie said, “He was walking, talking, eating, able to do everything independently which was awesome.” His room on rehab happened to be right next to the speech office and so the speech team got to know him really well. “He was one of those people who was so wonderful... and it could have been one of us. [As] a medical worker I think his story really was touching to me because he really fought, he was up and down when we didn’t know what was going on.”
Another patient Stefanie remembered was a woman who wouldn’t eat, who had dementia and COVID. “She wouldn’t even open her mouth,” said Stefanie. “So I went in and the medical resident came with me and we FaceTimed her sister. I was showing her she’s not eating, I don’t know what to tell you, I’m so sorry but maybe we should think about palliative care.” Shortly thereafter, visiting opened at the hospital, and the patient’s sister came to visit. Stefanie said how, “In the speech office we’d say this is the day she’s going to eat because her family is here.” And they were right. “Sure enough she opened her mouth and started eating, didn’t need a PEG (feeding tube), didn’t go on hospice, and she got to leave and go to a skilled nursing facility. Getting the family back was huge.” Patient experiences like this one remind Stefanie to keep up hope for her patients. “Not giving up on people was a big thing that we learned. It took so long for these [COVID] patients to recover, but eventually they got back a little bit.”
Regarding PPE, she said, “I never walked into a room without everything I needed, and I also was not willing to. I went out and bought hair nets in case I needed them, and right now my newest purchase is goggles because they changed the rules today that you need eye protection as well as a mask for all patient care.” Currently, Stefanie has a patient that is apraxic, and she’s been working with the patient to help her speak. “She can’t say anything and she’s in terrible shape, and I realized I rely so much on facial cues or my mouth and she can’t see me... I forgot. For us, communicating is our job, literally what we do all day, so we’re the ones bringing in pads of paper to patient rooms because they can’t understand us or we can’t understand them.”
In terms of COVID aftermath for healthcare workers, Stefanie reflected, “I think there’s going be a high incidence of voice problems. We’re screaming at patients because they can’t hear us, we’re screaming over negative pressure room filters, and it’s really loud. The ENTs are going to have a lot of work to do when we all come in with vocal cord nodules. But we’re all managing.” Stefanie is particularly concerned about her older patients who haven’t been able to access regular therapy over the last several months. “You have this really elderly population who doesn’t know how to use technology and is at really high risk to come out, and we’re totally missing them. We have no way to connect with them and that’s the community I’m worried about. They’re not getting services.” With the rehab unit re-opened, Stefanie says that it’s been constantly slammed, with no open beds, and a huge waitlist. The influx is due to the main hospital off-loading stabilized patients, who are not yet ready to go home. Due to the novelty of treating patients with COVID, Stefanie said, “It’s hard with patients because we don’t really know how much time they need. They’re so debilitated.”
On the acute care side of rehab, “The biggest and most cool thing we’re doing [as SLPs] is for patients who have trachs, we’re giving them speaking valves and letting them have a voice.” If the patients can’t tolerate the speaking valve, they can downsize their trachs, which allows them to breathe, talk, and swallow better. The acute care speech team also works with GI to assess swallowing and figure out if the patient needs a PEG (percutaneous endoscopic gastrostomy aka feeding tube). On the inpatient side, “We’re doing a lot of cognition [work], patients are confused, they’re delirious, they don’t know where they are or what the day is. No one has a window anymore because they pushed out all of the windows for the negative pressure system, so nobody knows if it’s daytime or nighttime, so [we need to] reorient them.” And then there’s the lack of clocks. Stefanie explained how a lot of the clocks in patients’ rooms mysteriously disappeared after getting cleaned due to COVID and they’ve yet to return.
Stefanie also works on respiration with patients using devices like an expiratory muscle strength trainer, the most common called “EMST150” which is a little device that goes in your mouth and “controls the strength in which you’re pulling air in an pushing air out, so it’s re-training the diaphragm to work as well as the lungs.” In addition to using this device to treat COVID patients, Stefanie said it’s also used to treat patients with spinal cord injury and Parkinson’s. “Muscles for swallowing and respiration are just like regular muscles in that we have to work them,” said Stefanie. “So when patients are super, super weak and they can’t walk, their swallow is going to stink also. Once they get stronger and they have a comprehensive rehab program, we’re seeing that everything gets better.” Stefanie explained how the speech team and the PM&R residents consult with each other, and it’s really a supportive teaching environment. “I try to get all of my PM&R residents to watch me do a FEES (fiberoptic endoscopic examination of swallowing) or a modified barium swallow exam, and so by April most of them know what I’m doing.” On her normal service, Stefanie works closely with the PM&R team to discuss patient care, and she said that the PM&R residents serve as important liaisons between the speech team and other departments like ENT.
Overall, Stefanie’s favorite part of rehab medicine is watching people improve. “You get someone and they’re having a really hard time and then all of a sudden they can go home.” To her, that’s what the work is all about.
R. Mayeda is a second year MD candidate at the Lewis Katz School of Medicine at Temple University in Philadelphia, Pennsylvania.