On this episode, Theresa sits down with Dr. Julie Cichero, a clinician, researcher, and one of the foremost experts in dysphagia with over 30 years of experience, to talk about something that has had a complicated reputation in our field: cervical auscultation. If you trained in the 90s, you probably learned it. If you trained more recently, you might have been told to ignore it. The truth, as it turns out, is a lot more nuanced than either camp wants to admit.
Dr. Cichero breaks down what the evidence actually shows, including sensitivities of around 91% and negative predictive values that should genuinely change how we think about using this tool at the bedside. She explains why it's not really about the "clink and clunk" sounds at all, and why the breathing pattern after the swallow is where the real clinical information lives. She also shares what proper training looks like, how cervical auscultation fits alongside instrumental assessment (not instead of it), and two clinical stories involving pharyngeal pouches that are honestly pretty wild.
Get the show notes and references here: https://syppodcast.com/393
The post 393 – Clinks, Clunks, and Clinical Confidence: Rethinking Cervical Auscultation – Julie Cichero BA, BSpThy(Hons), PhD appeared first on Swallow Your Pride Podcast.
Listen
Watch
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
Hello, my friends. Welcome back. On this episode
of the Sawyer Pride podcast, we have doctor
Julie Chiquiro.
She is a clinician SLP and researcher and
research professional with more than thirty years of
experience in dysphagia.
Julie is an honorary associate professor with the
School of Pharmacy and Pharmaceutical Sciences,
University of Queensland, and director of Eat Drink
(00:21):
Swallow Safe. She has made significant contributions to
the evidence based for standardized terminology for texture
modified food and thick liquids,
diagnostic use of swallow respiratory sounds, medication swallowing
issues, and characterization of thick fluids.
Julie holds workshops on dysphagia throughout Australia and
is an invited international speaker across Asia, Europe,
Canada, and The US.
(00:43):
Recognized nationally and internationally, Julie is a consultant
to professional societies, government organizations,
academia, coroners, boards, and health care organizations.
As cofounder of IDDSI Global, Julie co led
development of the IDDSI framework and initiative to
reduce choking risk in vulnerable populations.
The IDDSI framework is used in more than
50 countries around the world.
(01:05):
Julie has served as a clinical expert to
the aged care standards Expert Working Group for
the Australian Commission on Safety and Quality in
Health Care and as a consultant for the
Australian Stroke Foundation,
Speech Pathology Australia, Dietitians Australia, and the Society
of Hospital Pharmacists of Australia.
Julie has authored 80 journal articles and coauthored
four books. She is based in Brisbane, Australia,
(01:28):
and I hope you all love this conversation.
Welcome to the Swall Your Pride podcast. I'm
your host, Teresa Richard. I'm a board certified
specialist in swallowing and swallowing disorders,
(01:49):
a mobile fees business owner, and founder of
the MedSLP collective.
This podcast is all about delivering the latest
evidence based practice to medical SLPs everywhere.
Whether you're a new clinician seeking tangible tools
for treatment or a seasoned vet stuck in
a rut. My goal is to help ditch
the old school ways of the past that
no longer serve you or your patients, to
reinvigorate your passion for our field, to broaden
(02:11):
your knowledge about our scope of practice, and
to inspire you to practice at the top
of your license. So if you're listening, I
encourage you to swallow your pride, be open
and willing to learn because let's face it,
your patients deserve that kind of care. With
that, let's dive right in.
Just a quick disclaimer that all statements and
opinions expressed in this episode do not reflect
on the organizations associated with the speakers and
(02:34):
are their own opinions solely. Alright. Hello, doctor
Chiquiro. Good morning. How are you, Theresa? Good.
Thank you so much for joining me. Oh,
thank you so much for the invitation. I'm
thrilled to be here with you. Yeah. I
I felt like I've I've I've known of
you for years and years and years through
all this wonderful IDDSI work that you've been
doing, and then, some work you've been doing
in cervical auscultation popped up that I just
(02:56):
thought was really
fascinating and worth a a much more in-depth
conversation than a little social media blurb. So,
I'm glad we get to cover that today.
But first, if you wanna tell the people
a little bit about yourself. Yeah. Certainly.
So I'm a speech language pathologist,
of
approximately 30
now. So, I've worked across the age spectrum,
(03:17):
within pediatrics in a community setting, but most
of my work's actually been with adults in,
acute care, rehabilitation,
And I
my PhD was all about cervical auscultation.
It was,
I was working in acute care at the
time and, working in the stroke unit with
(03:39):
people who had very dense hemiplegias.
And if you can imagine, if you cast
your mind back thirty odd years ago,
to take patients down to a video fluoroscopy
suite, so we needed them to be stable.
We needed to swing that video fluoroscopy
up on its side so that patients then
had to
be able to balance on the footplate.
And if you've just had a very dense,
(04:00):
stroke, the ability to do that was, was
pretty challenging. And I found myself,
in the hospital rooms, you know, feeling for
hyalaryngeal
excursion, palpation,
doing the clinical bedside exam and thinking there's
gotta be something more that we can do
here when we can't get them to the
video fluoroscopy suite. So how can we keep
them safe in the meantime? And
(04:22):
at about the same time, I'd also been
part of a journal club at the hospital
that I worked with. And one of the
senior clinicians had brought in this journal paper,
by Susan Hamlet around using stethoscopes,
for swallowing sounds. And I thought what what
an unusual and and interesting concept. So I'm
still not sure whether to thank her or
(04:42):
or,
that's really how it started. Yeah. Yeah. And
and that's thank thank you for sharing that.
I think what's so fascinating is, you know,
being in this profession long enough now, which
is crazy to say is you sort of
see some of these trends come and go
for lack of a better term. And it
was you know, when I came out of
grad school, this was something that you did.
Right? This this was just something that you
(05:03):
did, and then it became this,
why would you do that? It all it
is, it doesn't tell us anything. It's just
hearing these weird sounds on a stethoscope and
doesn't actually tell us anything until it almost
became
blacklisted.
But then I feel in the last few
years, it's had this
reinvention almost that, hey. Perhaps there is something
there is some clinical use, some clinical utility
(05:25):
here. So, yeah, catch us up to date
on on where we are now. Yeah. No.
For sure. And I think,
look. Certainly at the time when I first
started, the the focus was really on the
swallowing sounds, and that's where my PhD started.
And when we were looking when I was
looking at the, you know, healthy sounds and
listening to
so I and, you know, if you read
the literature, the old literature, it talks about
(05:47):
these three swallowing sounds.
And I'll admit, when I first started listening,
I thought, this is crazy. Sometimes I'm hearing
five. Sometimes I'm hearing three.
How how do we work out what's helpful?
And it wasn't till I was sort of
partway through the PhD and then working clinically
again afterwards
where I realized it's actually not just the
swallowing sounds. So every time we, we swallow,
(06:10):
we obviously stop breathing. We had that apnea.
But there is a very consistent cycle that
starts happening with your breathing
from the moment you bring a cup up
to your mouth or a spoon up to
your mouth. And it is it's that cycle,
in fact, of what is that timing like?
Where does what happens with the breathing? Then
there's the swallowing, and then we come back
to the breathing.
(06:31):
And it's what's happening with the breathing afterwards
particularly that gives us some really valuable information.
So, you know, our airway is designed to
have air in it. So if you put
something like liquid in it, it sounds quite
different. We've got a hollow pipe there, and
it's a bit like putting the wrong fuel
in the wrong engine.
And the stethoscope
very definitely allows you to hear any changes
(06:54):
in breathing. So less about the swallowing sounds,
although sometimes they can be,
helpful as well. But, actually, what what is
the impact of that swallow
on our breathing system?
And, you know, when when I first started
again, I was looking at things like, well,
where else is this being used in medicine?
It's obviously been used in, listening to heart
(07:15):
sounds, listening to lung sounds. Do you know
with deep brain stimulation,
they actually use acoustics for the placement of
the electrodes
for deep brain stimulation as well? So, and
they know they're in the right spot by
by a change in the the way the
electrode sounds as it travels through different parts,
different layers of the brain, and it's considered
best practice
(07:36):
to use those acoustic signals.
So, you know, in a standard clinical exam,
we use our vision.
We're obviously very,
comfortable with that modality. That's what we rely
on for face. That's what we rely on
for video fluoroscopy.
We use palpation.
So why not use acoustics to enhance all
of our senses
(07:56):
so that we can get the very best
out of it? And, you know, when patients
aspirate or when their swallowing and breathing coordination
doesn't go well,
you'll hear things like, you know, whether it's,
whether it's wet breathing or fast breathing because
when you haven't got the usual oxygen exchange
happening,
the breathing system compensates for that, and you
often see an increased respiratory rate. So I
(08:19):
I guess that's that's probably part of it.
What else has changed?
I've done some fantastic work with doctor Liza
Bergstrom,
in Sweden
where we looked at structured training.
So when you've got people who just pick
up a stethoscope and walk out and do
their very best,
sure. We are bound to get a few
different
opinion, shall we say,
(08:40):
on what people have heard or or, what
their feelings are. And so Liza and I
designed a very structured program, and we were
able to demonstrate that when people go through
a structured program, that we're able to increase
inter and intra rater reliability.
And then beyond that, if you've got a
standard protocol that goes with it as well,
and that's something that we've just published this
(09:02):
year. So with, with Liza,
with Marion Jagber and Annalisa Sutt and myself.
So together, we've just published that protocol.
What's exciting about that protocol is that,
on the,
electronic copies,
that are available, there are nine swallow sounds
that are available for people to listen to
these nine swallow sounds so that you've got
(09:23):
the benefit of looking through and listening,
to the sounds while you're also reading the
protocol to hear what we're looking at with
that swallowing and breathing coordination and how that
changes for people with dysphagia. That's awesome. Thank
you for sharing that. I did not know
the the nitty gritty details of that. I
think, you know, last last I heard is,
you know, we hear clink and clunk, and
(09:43):
what does that mean, and and what
are we are we really, you know, saying
someone can eat or not eat based on
a clink or a clunk? So,
yeah, I hear you. I understand.
Yeah. Can you can you walk us through
a little bit more of of the sounds
or the protocol? I'm I'm really intrigued in
in what all that looks like. Yeah. No.
For sure. So,
(10:04):
really, it it means paying attention to people
from the beginning. So as they take the
the cup up to their mouth, for example.
With liquids, for example, we stop breathing while
the the liquid goes into the oral cavity.
In healthy people, obviously, you've got that swallow
happening within one to two seconds.
So you'll, you know, hear a a pause
in breathing. You hear the swallow sound, and
(10:24):
and I generally say to people, it's a
sound that you associate with swallowing. And then
in most healthy people, they will have a,
often an exhalation breath,
and then come back to their normal tidal
breathing.
The difference that we see in people with
dysphagia
is that if they've got an oral phase
impairment, it might take quite some time, and
(10:45):
you might hear some of the oral preparation,
or you might hear some early spillage, in
fact.
And if there is early spillage, if they've
if if that invades the airway, you know,
again, sometimes people will cough, and you obviously
don't need a stethoscope to hear that.
But sometimes you'll hear,
some, you know, subtle changes with that, a
(11:07):
swallow sound. And then if it has,
if they have aspirated, for example, or penetrated,
you may hear some subtle changes in their
breathing.
I usually say to people, make sure you
leave the stethoscope in place for a good
ten to fifteen seconds after the swallow so
that you can hear those changes in their
breathing. Because if there's been any, pharyngeal pooling,
(11:29):
for example, in the valleculi or the piriform
sinuses,
and the person starts breathing again as we
do, and they draw that material into the
airway,
you're likely to hear some changes to the
breathing sounds then. So I think what cervical
auscultation helps us to do is to ask
better questions.
It allows us to trial some different things,
and then we can check those things on
(11:50):
video fluoroscopy or face. So it is an
extra tool to the toolkit, if you like.
So that's that's really where a lot of
the, I guess, the protocol comes down to
is making sure you continue to listen
afterwards, after the swallow to see what the
what has the impact been of swallowing
on breathing? And I think that was one
(12:12):
of the interesting things when I started,
clinically to report some of that information,
in the the medical chart. So our standard
breathing rate, for example, is 16 to 20
breaths per minute for adults.
When someone has pneumonia, that breathing rate goes
up to around, you know, upwards of 28
to 30 breaths per minute. And our medical
(12:32):
colleagues recognize that as something very urgent that
needs to be managed. So
when I started to report, you know, a
change in breathing rate or an increase in
respiratory rate after someone had,
had a meal or had had a glass
of water,
my medical colleagues came and found me and
and were sort of saying, have you have
you assessed this person? Our medical colleagues
(12:53):
very definitely understand the importance of respiration.
So when we're able to demonstrate
importance
of of what impact swallowing has on breathing,
then we're able to work collaboratively really well
together as well. Love that. Thank you. Can
you share a little bit about, you know,
now now you've got my wheels turning about
the the use of this. Does this help
(13:14):
sometimes with that differential diagnosis or next steps
of, okay. You're seeing somebody in the clinic.
You're just doing clinical swallow eval. Now does
this help you pivot more towards fees or
video fluoroscopy? Does it just help you glean
a a better picture of what's going on
with the patient? Yeah. Absolutely. So look. I
I'm not averse to trying something like a
a chin tuck or a head rotation clinically.
(13:35):
You know? If if it if I haven't
got access
to our instrumental exams, I'm prepared to try
that if it means that I can more
safely have the person swallowing. So using the
stethoscope,
I I will try those techniques to see
if it makes any difference.
And so I've had patients, for example, following
a,
you know, a paralyzed vocal fold
(13:57):
and having them do a head rotation and
being able to hear
a crisp swallow, a clear you know, they
come straight back to normal breathing
as opposed to when their head's in the
midline,
and
and those things aren't happening. And so there's
a a delay,
and you can often hear the a change
to how their breathing happens
(14:18):
afterwards.
I've had,
occasions as well where, you know, like, if
we've tried thickened liquids, for example,
you know, has
and you wanna go to just the smallest
amount of thickening needed to make a change
for them because, you know, we wanna make
sure that we're not,
that that we retain quality of life and
and, obviously, hydration and all of those things
(14:38):
as well. But if we try something,
you know, whether it's a thick liquid, whether
it's a a puree or a minced and
moist, to see what impact that has, does
it mean that they are chewing more efficiently
or their oral phase is more efficient, and
that their, that their swallowing happens more promptly
and that they come back to normal tidal
breathing again afterwards? So it's it's kind of
(15:01):
that sequence of steps that you're looking for.
And so therefore, when we go,
to video fluoroscopy, particularly where you, might be
concerned about radiation exposure time, to be able
to say, we absolutely have to check this
consistency and this consistency.
I think based on what I'm hearing clinically,
(15:21):
using the stethoscope that this one might be
better for them, but I'd like to check.
And, you know, if it doesn't work out
that way, then you've learned something as well.
It means that you've learned something from that
individual.
Yeah. Yeah. Can you talk a little bit
more about what you guys have found as
far as comparing it to instrumental assessments? Yes.
So there has been, really quite good reliability
(15:43):
and validity,
with cervical auscultation. So I think some of
the work also done by
Twi Fracking,
most recently and Annalisa Kron,
we're looking at sensitivities of about ninety one
percent and and specificities of about seventy nine
percent compared with whether it's video fluoroscopy or
with Feasts, for example.
(16:03):
So that that's very good. You know, it
it gives us confidence. I think the other
thing that, that we've been able to demonstrate
when you look at
cervical auscultation,
compared with the instrumental exams,
is that you've got very good,
negative predictive value. And what that means is
that when you hear a swallow,
(16:23):
sequence, a swallow respiratory sequence
that sounds like a healthy sequence,
99
98%
of the time, it is a healthy sequence.
So you can feel confident
that if it sounds good, it is.
That became really helpful actually with a I
remember a patient who I saw who, had
a very high,
(16:43):
body mass index. So he it was you
know, he had a very thick neck. I
couldn't feel his larynx at all,
and and I wondered how I was going
to assess this gentleman. We, you know, we
were able to do the the oromotor, but
I I could not feel his, his larynx
for palpation or hyoid at all. But in
being able to put the stethoscope,
(17:04):
onto his neck, and because the, you know,
depending on where you place the stethoscope as
well, if you're placing it quite anteriorly over
the the trachea,
you don't have the muscles. So the muscles
actually come on the, obviously, the sternocleidomastoid
on the side of the neck. But by
placing it directly underneath
the cricoid cartilage so that it's resting on
(17:24):
the trachea there, I was able to to
quite clearly hear his breathing and his swallowing
coordination. So that was very helpful,
in in that case as well. I I
realize I've just delved I've gone from literature
back into a clinical example there. It's all
wonderful. Yeah. Yeah. But and I just think
of you know, most of my career has
been in doing fees, and I just think
(17:45):
of some of these patients that it's just
difficult to get a fees or, you know,
if you think of someone with large body
mass index, sometimes you get in there and
there's just so much edema. You can't even
you can barely even visualize the cords, you
know, and then you feel bad about having
an incomplete study or not being able to
give them any sort of information.
And so this, this is excellent, I feel
like. And and like you said, just another
(18:06):
tool that, you know, we we can glean
some clinical information that that is reliable. Yeah.
I think the most interesting thing,
that I found, and and it it's it
was more it's not a fluke because it's
happened a couple of times.
Was listening to a patient where you know,
was listening to that coordination
happening.
They'd come in actually talking about,
(18:28):
feeling that material was stuck in their throat
and complaining particularly about grapes. And in fact,
they'd eaten some grapes just before they came
in for their clinical exam.
Everything else was was largely normal, and this
had been going on for some time. They'd
seen doctors,
blah blah blah,
and
did the cervical auscultation exam, and the swallow
(18:48):
sound itself was fine.
And I realized that they'd come back to
normal tidal breathing, but I could hear additional
sounds.
I wanna call them sort of squelching sounds
that that were consistent, that kept happening there.
And and I said to them, are you
feeling you know, you talk about this thing
being caught in your throat. Can you feel
that? And she said, I can. I can,
actually,
and sort of pointed.
(19:09):
And
so as I was listening, like, you you're
really doing some problem solving at the same
time. So okay. If if the chewing was
good, if the swallow sound was there, if
she came back to tidal breathing and I'm
hearing additional sounds, what else could this be?
And so the the question
that I posed based on where she was
pointing, which was, you know, roughly at the
(19:31):
sternal notch there,
was to send her off to a,
a video fluoroscopy
to ask about,
was it potentially an an abnormality? Was it
potentially a pharyngeal pouch or some abnormality in
the upper cervical region?
So anyway, she came back following her video
fluoroscopy, and it was a pharyngeal pouch, And
(19:52):
they were able to treat it, and, yeah,
it was clearly identifying.
And and, you know, a couple of years
later, I was at a, in an acute
hospital
with a a lady in her early eighties,
I think it was, and very similar presentation.
Again, hearing this unusual sound,
after the after the swallow,
but on the background of normal tidal breathing.
(20:14):
So the breathing was there with this additional
sound. And I said to her, this is,
you know, I explained what was happening. Her
cognition was good. She was able to understand.
She was frail.
And I said, I'm I'm thinking that it
would be good if we had a video
fluoroscopy so that we could check to see
whether there might be something called a pharyngeal
patch. And she said, I know exactly what
you're talking about. I was treated for that
(20:36):
seven years ago, and, yeah, they repaired it.
So so that benefit was an completely unexpected
thing,
but, again, it's a tool in the toolkit.
It's helpful
to then pass on. As you say, FEAST
provides us so much wonderful information
about particularly around, saliva control, secretion management, for
(20:56):
example.
And I can think for our, chronic obstructive
pulmonary disease patients,
I could see a real benefit in doing
a cervical
auscultation exam, and then following up with a
face exam, for example.
So in doing the training,
so I've been doing training for more than
twenty five years now.
At times, I've had opportunity to speak to
(21:17):
clinicians, and I've, you know, I've said to
them, look, email me if you've got questions.
And, a couple of them have said, you
know, look, I I I really enjoyed the
course. It was great. But when I got
back to work, I wasn't,
I didn't find it as helpful. And I
said, okay. Well, talk me through that. And
they said, you know, I used it for
the patients
that I wasn't quite sure about. And I
said, ah, okay. So the difference is this,
(21:39):
if you use it and listen to healthy
people as well, it's like we're building our
own internal Spotify list. We actually have to
build what does normal sound like in order
that we understand what those abnormal patterns sound
like. So if we try and train our
brain only playing at expert level,
it makes it really hard because we haven't
done the earlier work to start with. And
(22:00):
so that I guess that's one of the
key tips that I have for people
is to make sure to listen to every
single swallow. There is something that you will
learn from every person, and having the person
in front of you as you do that,
that's the other thing that really helps. Just
listening to random sounds without the visual of
the person in front of you is really,
(22:21):
really hard, in fact. Having
the person being able to ask questions,
putting all of it together, I think, is
where the real utility comes from and using
it continuously.
And, you know, when I first started using
cervical auscultation and and again in training, I
say to people, you know, listen for a
good, you know, two, three weeks full time
(22:44):
before you even put pen to paper in
the clinical records and ask questions.
The yeah. They they would be some of
my top tips. I I'd like to give
you an opportunity to to stake your
opinion about this replacing
instrumental assessments or not. And and I know
that's always you know, people are gonna say,
oh, we don't need instrumentals anymore. We can
(23:05):
just do this and yes. So I'm gonna
I'm gonna allow you to have the floor
to clear that up. Thanks, Theresa. Yes.
No. It doesn't replace it. You know, let's
face it. We when I listen to that
and I've had people say, oh, can you
hear when it's in the piriform or the
molecularly? Can you can you hear where it
is? And I said, no. We can't we
can't actually hear. We can say that there
(23:26):
there are sounds that tell us that there
is material that's retained in the pharynx.
Where that is, of course, we need instrumental
exams for it. So it is a complimentary
tool. It's a very good it's beyond screening
because you do need training for it. So
it's not the kind of thing that just
anyone can pick up. You you know,
training is important for it.
(23:48):
But it is designed to work hand in
glove with instrumental assessment.
If I was in a, a facility so
in Australia, we have a really remote
we have some very remote communities,
and it is possible that there may not
be access to video fluoroscopy,
or face for that matter for for a
(24:08):
period of time
rather than have that person
nil by mouth. Might I make some recommendations
very, very,
closely guarded where you'd would continue to come
back and check. You'd be looking for all
of your other, you know, medical indicators,
you know, whether they're,
it might be a problem with it where
that might cause you to change your mind
(24:30):
and and,
increase the urgency of of that instrumental exam.
So that that's what I would say. In
a in a situation where you've got access
to instrumental exam,
it is something that you would do
beforehand to allow you to make better ask
better questions of your face and of your
video fluoroscopy, I think. Yeah. Yeah. Thank you.
(24:51):
I I can think of just so many
instances of where it would be just really
valuable. Like you said, you know, I I
used to work in very rural parts of
New York state where I would drive four
hours to the closest facility to see patients
for fees and, you know, just thinking having
you know, I I really liked what you
said about the negative predictive
values
of knowing that, okay, this patient is is
(25:12):
somewhat safe, you know, without further instrumental assessment.
But then even, you know, I think of
even some of these very urban hospitals that
may only have two
fluoro spots for the week, and you've got
a triage all of these. You know, there's
20 patients that you might be recommending for
these two spots. You know, I think there's
a lot of clinical utility in how we
triage patients as well and and, you know,
(25:34):
making priorities out of some patients and others,
you know, we can provide some clinical recommendations
in the meantime. So Yeah. Yeah. No. I
I couldn't agree more. Is there anything else
that we didn't cover? Anything else you wanna
add? Can I share an anecdote? Of course.
Probably the only other thing I wanted to
share was,
that would have been back in 1996,
I think,
(25:54):
as a as a PhD student where I
was presenting in Australia, and we had professor
Logerman attending.
And so I I presented part of my
PhD protocol. I remember a couple of other
people, someone else presenting about the utility of
listening to wet voice,
and professor Logerman
(26:15):
stood up and basically told us we're all
wasting our time.
That why would you do anything other than
video fluoroscopy?
And I remember feeling just so completely deflated
at the time and and walking out and,
you know,
reconsidering my life choices, shall we say, from
an academic and professional,
(26:36):
perspective.
And
it wasn't until a number of and and
I'm I stayed in touch with her, actually.
She's such a lovely lady and very generous
with her time. Very strict, very you know,
like, you needed to know your stuff.
But after I'd completed my PhD and gosh.
It was probably it was a number of
years later and published a number of things
and started doing training
(26:57):
where I caught up with her afterwards. And
she emailed to say, do you know it
was a bit harsh? I think there probably
is some utility to it.
And so that that was really nice,
you know, as a as a an experience
to have that kind of tied off at
the end if you like. Yeah. I I
think we all have our experiences where we
stick our stake in the ground and say,
(27:17):
best yeah. I was like that with fees
for the longest time. Like, this is the
best thing in the whole wide world and
everything else, we don't need it, you know.
And and I had to I had to
soften that approach because I truly didn't feel
that way. I just was very passionate about
the tool that I had access to, you
know. So Yeah. Yeah. Yeah. I think as
we get older and more experienced, we realize
that all of these play a role in
in all of the things we do.
(27:39):
Exactly. That's exactly right. And, you know, you
you'll use the best tool at the time
for what you have and and what's available
to you. Yeah. Yep. Alright. Well, thank you.
Thank you so much, Julia. I really appreciate
this conversation. I think this is just it's
it's eye opening, but it's also comforting to
know that, you know, this this was a
tool that was very valuable for a long
time, and and I think just the the
(28:00):
proper
training and education
is really the key with all of this
stuff. So thank you. Thank you. Thank you.
Thank you. Thanks so much for the opportunity,
Theresa.
And that's a wrap for this episode. As
always, thank you so much for listening.
If you'd like to download the show notes
from this episode, please visit swallowyourpridepodcast.com.
There you can also sign up for our
(28:21):
email list so that you'll never miss another
episode.
If you do like what you hear, then
please subscribe and leave a review on iTunes,
or or share it on social media with
your friends and colleagues, because that is what
keeps these episodes coming.
If you'd like to be a guest, share
feedback, or request a topic to be discussed
on the show, please email podcast@TeresaRichard.com.
(28:43):
Thank you so much for listening, and we'll
catch you next week.
Hello, my friends. Welcome back. On this episode
of the Sawyer Pride podcast, we have doctor
Julie Chiquiro.
She is a clinician SLP and researcher and
research professional with more than thirty years of
experience in dysphagia.
Julie is an honorary associate professor with the
School of Pharmacy and Pharmaceutical Sciences,
University of Queensland, and director of Eat Drink
(00:21):
Swallow Safe. She has made significant contributions to
the evidence based for standardized terminology for texture
modified food and thick liquids,
diagnostic use of swallow respiratory sounds, medication swallowing
issues, and characterization of thick fluids.
Julie holds workshops on dysphagia throughout Australia and
is an invited international speaker across Asia, Europe,
Canada, and The US.
(00:43):
Recognized nationally and internationally, Julie is a consultant
to professional societies, government organizations,
academia, coroners, boards, and health care organizations.
As cofounder of IDDSI Global, Julie co led
development of the IDDSI framework and initiative to
reduce choking risk in vulnerable populations.
The IDDSI framework is used in more than
50 countries around the world.
(01:05):
Julie has served as a clinical expert to
the aged care standards Expert Working Group for
the Australian Commission on Safety and Quality in
Health Care and as a consultant for the
Australian Stroke Foundation,
Speech Pathology Australia, Dietitians Australia, and the Society
of Hospital Pharmacists of Australia.
Julie has authored 80 journal articles and coauthored
four books. She is based in Brisbane, Australia,
(01:28):
and I hope you all love this conversation.
Welcome to the Swall Your Pride podcast. I'm
your host, Teresa Richard. I'm a board certified
specialist in swallowing and swallowing disorders,
(01:49):
a mobile fees business owner, and founder of
the MedSLP collective.
This podcast is all about delivering the latest
evidence based practice to medical SLPs everywhere.
Whether you're a new clinician seeking tangible tools
for treatment or a seasoned vet stuck in
a rut. My goal is to help ditch
the old school ways of the past that
no longer serve you or your patients, to
reinvigorate your passion for our field, to broaden
(02:11):
your knowledge about our scope of practice, and
to inspire you to practice at the top
of your license. So if you're listening, I
encourage you to swallow your pride, be open
and willing to learn because let's face it,
your patients deserve that kind of care. With
that, let's dive right in.
Just a quick disclaimer that all statements and
opinions expressed in this episode do not reflect
on the organizations associated with the speakers and
(02:34):
are their own opinions solely. Alright. Hello, doctor
Chiquiro. Good morning. How are you, Theresa? Good.
Thank you so much for joining me. Oh,
thank you so much for the invitation. I'm
thrilled to be here with you. Yeah. I
I felt like I've I've I've known of
you for years and years and years through
all this wonderful IDDSI work that you've been
doing, and then, some work you've been doing
in cervical auscultation popped up that I just
(02:56):
thought was really
fascinating and worth a a much more in-depth
conversation than a little social media blurb. So,
I'm glad we get to cover that today.
But first, if you wanna tell the people
a little bit about yourself. Yeah. Certainly.
So I'm a speech language pathologist,
of
approximately 30
now. So, I've worked across the age spectrum,
(03:17):
within pediatrics in a community setting, but most
of my work's actually been with adults in,
acute care, rehabilitation,
And I
my PhD was all about cervical auscultation.
It was,
I was working in acute care at the
time and, working in the stroke unit with
(03:39):
people who had very dense hemiplegias.
And if you can imagine, if you cast
your mind back thirty odd years ago,
to take patients down to a video fluoroscopy
suite, so we needed them to be stable.
We needed to swing that video fluoroscopy
up on its side so that patients then
had to
be able to balance on the footplate.
And if you've just had a very dense,
(04:00):
stroke, the ability to do that was, was
pretty challenging. And I found myself,
in the hospital rooms, you know, feeling for
hyalaryngeal
excursion, palpation,
doing the clinical bedside exam and thinking there's
gotta be something more that we can do
here when we can't get them to the
video fluoroscopy suite. So how can we keep
them safe in the meantime? And
(04:22):
at about the same time, I'd also been
part of a journal club at the hospital
that I worked with. And one of the
senior clinicians had brought in this journal paper,
by Susan Hamlet around using stethoscopes,
for swallowing sounds. And I thought what what
an unusual and and interesting concept. So I'm
still not sure whether to thank her or
(04:42):
or,
that's really how it started. Yeah. Yeah. And
and that's thank thank you for sharing that.
I think what's so fascinating is, you know,
being in this profession long enough now, which
is crazy to say is you sort of
see some of these trends come and go
for lack of a better term. And it
was you know, when I came out of
grad school, this was something that you did.
Right? This this was just something that you
(05:03):
did, and then it became this,
why would you do that? It all it
is, it doesn't tell us anything. It's just
hearing these weird sounds on a stethoscope and
doesn't actually tell us anything until it almost
became
blacklisted.
But then I feel in the last few
years, it's had this
reinvention almost that, hey. Perhaps there is something
there is some clinical use, some clinical utility
(05:25):
here. So, yeah, catch us up to date
on on where we are now. Yeah. No.
For sure. And I think,
look. Certainly at the time when I first
started, the the focus was really on the
swallowing sounds, and that's where my PhD started.
And when we were looking when I was
looking at the, you know, healthy sounds and
listening to
so I and, you know, if you read
the literature, the old literature, it talks about
(05:47):
these three swallowing sounds.
And I'll admit, when I first started listening,
I thought, this is crazy. Sometimes I'm hearing
five. Sometimes I'm hearing three.
How how do we work out what's helpful?
And it wasn't till I was sort of
partway through the PhD and then working clinically
again afterwards
where I realized it's actually not just the
swallowing sounds. So every time we, we swallow,
(06:10):
we obviously stop breathing. We had that apnea.
But there is a very consistent cycle that
starts happening with your breathing
from the moment you bring a cup up
to your mouth or a spoon up to
your mouth. And it is it's that cycle,
in fact, of what is that timing like?
Where does what happens with the breathing? Then
there's the swallowing, and then we come back
to the breathing.
(06:31):
And it's what's happening with the breathing afterwards
particularly that gives us some really valuable information.
So, you know, our airway is designed to
have air in it. So if you put
something like liquid in it, it sounds quite
different. We've got a hollow pipe there, and
it's a bit like putting the wrong fuel
in the wrong engine.
And the stethoscope
very definitely allows you to hear any changes
(06:54):
in breathing. So less about the swallowing sounds,
although sometimes they can be,
helpful as well. But, actually, what what is
the impact of that swallow
on our breathing system?
And, you know, when when I first started
again, I was looking at things like, well,
where else is this being used in medicine?
It's obviously been used in, listening to heart
(07:15):
sounds, listening to lung sounds. Do you know
with deep brain stimulation,
they actually use acoustics for the placement of
the electrodes
for deep brain stimulation as well? So, and
they know they're in the right spot by
by a change in the the way the
electrode sounds as it travels through different parts,
different layers of the brain, and it's considered
best practice
(07:36):
to use those acoustic signals.
So, you know, in a standard clinical exam,
we use our vision.
We're obviously very,
comfortable with that modality. That's what we rely
on for face. That's what we rely on
for video fluoroscopy.
We use palpation.
So why not use acoustics to enhance all
of our senses
(07:56):
so that we can get the very best
out of it? And, you know, when patients
aspirate or when their swallowing and breathing coordination
doesn't go well,
you'll hear things like, you know, whether it's,
whether it's wet breathing or fast breathing because
when you haven't got the usual oxygen exchange
happening,
the breathing system compensates for that, and you
often see an increased respiratory rate. So I
(08:19):
I guess that's that's probably part of it.
What else has changed?
I've done some fantastic work with doctor Liza
Bergstrom,
in Sweden
where we looked at structured training.
So when you've got people who just pick
up a stethoscope and walk out and do
their very best,
sure. We are bound to get a few
different
opinion, shall we say,
(08:40):
on what people have heard or or, what
their feelings are. And so Liza and I
designed a very structured program, and we were
able to demonstrate that when people go through
a structured program, that we're able to increase
inter and intra rater reliability.
And then beyond that, if you've got a
standard protocol that goes with it as well,
and that's something that we've just published this
(09:02):
year. So with, with Liza,
with Marion Jagber and Annalisa Sutt and myself.
So together, we've just published that protocol.
What's exciting about that protocol is that,
on the,
electronic copies,
that are available, there are nine swallow sounds
that are available for people to listen to
these nine swallow sounds so that you've got
(09:23):
the benefit of looking through and listening,
to the sounds while you're also reading the
protocol to hear what we're looking at with
that swallowing and breathing coordination and how that
changes for people with dysphagia. That's awesome. Thank
you for sharing that. I did not know
the the nitty gritty details of that. I
think, you know, last last I heard is,
you know, we hear clink and clunk, and
(09:43):
what does that mean, and and what
are we are we really, you know, saying
someone can eat or not eat based on
a clink or a clunk? So,
yeah, I hear you. I understand.
Yeah. Can you can you walk us through
a little bit more of of the sounds
or the protocol? I'm I'm really intrigued in
in what all that looks like. Yeah. No.
For sure. So,
(10:04):
really, it it means paying attention to people
from the beginning. So as they take the
the cup up to their mouth, for example.
With liquids, for example, we stop breathing while
the the liquid goes into the oral cavity.
In healthy people, obviously, you've got that swallow
happening within one to two seconds.
So you'll, you know, hear a a pause
in breathing. You hear the swallow sound, and
(10:24):
and I generally say to people, it's a
sound that you associate with swallowing. And then
in most healthy people, they will have a,
often an exhalation breath,
and then come back to their normal tidal
breathing.
The difference that we see in people with
dysphagia
is that if they've got an oral phase
impairment, it might take quite some time, and
(10:45):
you might hear some of the oral preparation,
or you might hear some early spillage, in
fact.
And if there is early spillage, if they've
if if that invades the airway, you know,
again, sometimes people will cough, and you obviously
don't need a stethoscope to hear that.
But sometimes you'll hear,
some, you know, subtle changes with that, a
(11:07):
swallow sound. And then if it has,
if they have aspirated, for example, or penetrated,
you may hear some subtle changes in their
breathing.
I usually say to people, make sure you
leave the stethoscope in place for a good
ten to fifteen seconds after the swallow so
that you can hear those changes in their
breathing. Because if there's been any, pharyngeal pooling,
(11:29):
for example, in the valleculi or the piriform
sinuses,
and the person starts breathing again as we
do, and they draw that material into the
airway,
you're likely to hear some changes to the
breathing sounds then. So I think what cervical
auscultation helps us to do is to ask
better questions.
It allows us to trial some different things,
and then we can check those things on
(11:50):
video fluoroscopy or face. So it is an
extra tool to the toolkit, if you like.
So that's that's really where a lot of
the, I guess, the protocol comes down to
is making sure you continue to listen
afterwards, after the swallow to see what the
what has the impact been of swallowing
on breathing? And I think that was one
(12:12):
of the interesting things when I started,
clinically to report some of that information,
in the the medical chart. So our standard
breathing rate, for example, is 16 to 20
breaths per minute for adults.
When someone has pneumonia, that breathing rate goes
up to around, you know, upwards of 28
to 30 breaths per minute. And our medical
(12:32):
colleagues recognize that as something very urgent that
needs to be managed. So
when I started to report, you know, a
change in breathing rate or an increase in
respiratory rate after someone had,
had a meal or had had a glass
of water,
my medical colleagues came and found me and
and were sort of saying, have you have
you assessed this person? Our medical colleagues
(12:53):
very definitely understand the importance of respiration.
So when we're able to demonstrate
importance
of of what impact swallowing has on breathing,
then we're able to work collaboratively really well
together as well. Love that. Thank you. Can
you share a little bit about, you know,
now now you've got my wheels turning about
the the use of this. Does this help
(13:14):
sometimes with that differential diagnosis or next steps
of, okay. You're seeing somebody in the clinic.
You're just doing clinical swallow eval. Now does
this help you pivot more towards fees or
video fluoroscopy? Does it just help you glean
a a better picture of what's going on
with the patient? Yeah. Absolutely. So look. I
I'm not averse to trying something like a
a chin tuck or a head rotation clinically.
(13:35):
You know? If if it if I haven't
got access
to our instrumental exams, I'm prepared to try
that if it means that I can more
safely have the person swallowing. So using the
stethoscope,
I I will try those techniques to see
if it makes any difference.
And so I've had patients, for example, following
a,
you know, a paralyzed vocal fold
(13:57):
and having them do a head rotation and
being able to hear
a crisp swallow, a clear you know, they
come straight back to normal breathing
as opposed to when their head's in the
midline,
and
and those things aren't happening. And so there's
a a delay,
and you can often hear the a change
to how their breathing happens
(14:18):
afterwards.
I've had,
occasions as well where, you know, like, if
we've tried thickened liquids, for example,
you know, has
and you wanna go to just the smallest
amount of thickening needed to make a change
for them because, you know, we wanna make
sure that we're not,
that that we retain quality of life and
and, obviously, hydration and all of those things
(14:38):
as well. But if we try something,
you know, whether it's a thick liquid, whether
it's a a puree or a minced and
moist, to see what impact that has, does
it mean that they are chewing more efficiently
or their oral phase is more efficient, and
that their, that their swallowing happens more promptly
and that they come back to normal tidal
breathing again afterwards? So it's it's kind of
(15:01):
that sequence of steps that you're looking for.
And so therefore, when we go,
to video fluoroscopy, particularly where you, might be
concerned about radiation exposure time, to be able
to say, we absolutely have to check this
consistency and this consistency.
I think based on what I'm hearing clinically,
(15:21):
using the stethoscope that this one might be
better for them, but I'd like to check.
And, you know, if it doesn't work out
that way, then you've learned something as well.
It means that you've learned something from that
individual.
Yeah. Yeah. Can you talk a little bit
more about what you guys have found as
far as comparing it to instrumental assessments? Yes.
So there has been, really quite good reliability
(15:43):
and validity,
with cervical auscultation. So I think some of
the work also done by
Twi Fracking,
most recently and Annalisa Kron,
we're looking at sensitivities of about ninety one
percent and and specificities of about seventy nine
percent compared with whether it's video fluoroscopy or
with Feasts, for example.
(16:03):
So that that's very good. You know, it
it gives us confidence. I think the other
thing that, that we've been able to demonstrate
when you look at
cervical auscultation,
compared with the instrumental exams,
is that you've got very good,
negative predictive value. And what that means is
that when you hear a swallow,
(16:23):
sequence, a swallow respiratory sequence
that sounds like a healthy sequence,
99
98%
of the time, it is a healthy sequence.
So you can feel confident
that if it sounds good, it is.
That became really helpful actually with a I
remember a patient who I saw who, had
a very high,
(16:43):
body mass index. So he it was you
know, he had a very thick neck. I
couldn't feel his larynx at all,
and and I wondered how I was going
to assess this gentleman. We, you know, we
were able to do the the oromotor, but
I I could not feel his, his larynx
for palpation or hyoid at all. But in
being able to put the stethoscope,
(17:04):
onto his neck, and because the, you know,
depending on where you place the stethoscope as
well, if you're placing it quite anteriorly over
the the trachea,
you don't have the muscles. So the muscles
actually come on the, obviously, the sternocleidomastoid
on the side of the neck. But by
placing it directly underneath
the cricoid cartilage so that it's resting on
(17:24):
the trachea there, I was able to to
quite clearly hear his breathing and his swallowing
coordination. So that was very helpful,
in in that case as well. I I
realize I've just delved I've gone from literature
back into a clinical example there. It's all
wonderful. Yeah. Yeah. But and I just think
of you know, most of my career has
been in doing fees, and I just think
(17:45):
of some of these patients that it's just
difficult to get a fees or, you know,
if you think of someone with large body
mass index, sometimes you get in there and
there's just so much edema. You can't even
you can barely even visualize the cords, you
know, and then you feel bad about having
an incomplete study or not being able to
give them any sort of information.
And so this, this is excellent, I feel
like. And and like you said, just another
(18:06):
tool that, you know, we we can glean
some clinical information that that is reliable. Yeah.
I think the most interesting thing,
that I found, and and it it's it
was more it's not a fluke because it's
happened a couple of times.
Was listening to a patient where you know,
was listening to that coordination
happening.
They'd come in actually talking about,
(18:28):
feeling that material was stuck in their throat
and complaining particularly about grapes. And in fact,
they'd eaten some grapes just before they came
in for their clinical exam.
Everything else was was largely normal, and this
had been going on for some time. They'd
seen doctors,
blah blah blah,
and
did the cervical auscultation exam, and the swallow
(18:48):
sound itself was fine.
And I realized that they'd come back to
normal tidal breathing, but I could hear additional
sounds.
I wanna call them sort of squelching sounds
that that were consistent, that kept happening there.
And and I said to them, are you
feeling you know, you talk about this thing
being caught in your throat. Can you feel
that? And she said, I can. I can,
actually,
and sort of pointed.
(19:09):
And
so as I was listening, like, you you're
really doing some problem solving at the same
time. So okay. If if the chewing was
good, if the swallow sound was there, if
she came back to tidal breathing and I'm
hearing additional sounds, what else could this be?
And so the the question
that I posed based on where she was
pointing, which was, you know, roughly at the
(19:31):
sternal notch there,
was to send her off to a,
a video fluoroscopy
to ask about,
was it potentially an an abnormality? Was it
potentially a pharyngeal pouch or some abnormality in
the upper cervical region?
So anyway, she came back following her video
fluoroscopy, and it was a pharyngeal pouch, And
(19:52):
they were able to treat it, and, yeah,
it was clearly identifying.
And and, you know, a couple of years
later, I was at a, in an acute
hospital
with a a lady in her early eighties,
I think it was, and very similar presentation.
Again, hearing this unusual sound,
after the after the swallow,
but on the background of normal tidal breathing.
(20:14):
So the breathing was there with this additional
sound. And I said to her, this is,
you know, I explained what was happening. Her
cognition was good. She was able to understand.
She was frail.
And I said, I'm I'm thinking that it
would be good if we had a video
fluoroscopy so that we could check to see
whether there might be something called a pharyngeal
patch. And she said, I know exactly what
you're talking about. I was treated for that
(20:36):
seven years ago, and, yeah, they repaired it.
So so that benefit was an completely unexpected
thing,
but, again, it's a tool in the toolkit.
It's helpful
to then pass on. As you say, FEAST
provides us so much wonderful information
about particularly around, saliva control, secretion management, for
(20:56):
example.
And I can think for our, chronic obstructive
pulmonary disease patients,
I could see a real benefit in doing
a cervical
auscultation exam, and then following up with a
face exam, for example.
So in doing the training,
so I've been doing training for more than
twenty five years now.
At times, I've had opportunity to speak to
(21:17):
clinicians, and I've, you know, I've said to
them, look, email me if you've got questions.
And, a couple of them have said, you
know, look, I I I really enjoyed the
course. It was great. But when I got
back to work, I wasn't,
I didn't find it as helpful. And I
said, okay. Well, talk me through that. And
they said, you know, I used it for
the patients
that I wasn't quite sure about. And I
said, ah, okay. So the difference is this,
(21:39):
if you use it and listen to healthy
people as well, it's like we're building our
own internal Spotify list. We actually have to
build what does normal sound like in order
that we understand what those abnormal patterns sound
like. So if we try and train our
brain only playing at expert level,
it makes it really hard because we haven't
done the earlier work to start with. And
(22:00):
so that I guess that's one of the
key tips that I have for people
is to make sure to listen to every
single swallow. There is something that you will
learn from every person, and having the person
in front of you as you do that,
that's the other thing that really helps. Just
listening to random sounds without the visual of
the person in front of you is really,
(22:21):
really hard, in fact. Having
the person being able to ask questions,
putting all of it together, I think, is
where the real utility comes from and using
it continuously.
And, you know, when I first started using
cervical auscultation and and again in training, I
say to people, you know, listen for a
good, you know, two, three weeks full time
(22:44):
before you even put pen to paper in
the clinical records and ask questions.
The yeah. They they would be some of
my top tips. I I'd like to give
you an opportunity to to stake your
opinion about this replacing
instrumental assessments or not. And and I know
that's always you know, people are gonna say,
oh, we don't need instrumentals anymore. We can
(23:05):
just do this and yes. So I'm gonna
I'm gonna allow you to have the floor
to clear that up. Thanks, Theresa. Yes.
No. It doesn't replace it. You know, let's
face it. We when I listen to that
and I've had people say, oh, can you
hear when it's in the piriform or the
molecularly? Can you can you hear where it
is? And I said, no. We can't we
can't actually hear. We can say that there
(23:26):
there are sounds that tell us that there
is material that's retained in the pharynx.
Where that is, of course, we need instrumental
exams for it. So it is a complimentary
tool. It's a very good it's beyond screening
because you do need training for it. So
it's not the kind of thing that just
anyone can pick up. You you know,
training is important for it.
(23:48):
But it is designed to work hand in
glove with instrumental assessment.
If I was in a, a facility so
in Australia, we have a really remote
we have some very remote communities,
and it is possible that there may not
be access to video fluoroscopy,
or face for that matter for for a
(24:08):
period of time
rather than have that person
nil by mouth. Might I make some recommendations
very, very,
closely guarded where you'd would continue to come
back and check. You'd be looking for all
of your other, you know, medical indicators,
you know, whether they're,
it might be a problem with it where
that might cause you to change your mind
(24:30):
and and,
increase the urgency of of that instrumental exam.
So that that's what I would say. In
a in a situation where you've got access
to instrumental exam,
it is something that you would do
beforehand to allow you to make better ask
better questions of your face and of your
video fluoroscopy, I think. Yeah. Yeah. Thank you.
(24:51):
I I can think of just so many
instances of where it would be just really
valuable. Like you said, you know, I I
used to work in very rural parts of
New York state where I would drive four
hours to the closest facility to see patients
for fees and, you know, just thinking having
you know, I I really liked what you
said about the negative predictive
values
of knowing that, okay, this patient is is
(25:12):
somewhat safe, you know, without further instrumental assessment.
But then even, you know, I think of
even some of these very urban hospitals that
may only have two
fluoro spots for the week, and you've got
a triage all of these. You know, there's
20 patients that you might be recommending for
these two spots. You know, I think there's
a lot of clinical utility in how we
triage patients as well and and, you know,
(25:34):
making priorities out of some patients and others,
you know, we can provide some clinical recommendations
in the meantime. So Yeah. Yeah. No. I
I couldn't agree more. Is there anything else
that we didn't cover? Anything else you wanna
add? Can I share an anecdote? Of course.
Probably the only other thing I wanted to
share was,
that would have been back in 1996,
I think,
(25:54):
as a as a PhD student where I
was presenting in Australia, and we had professor
Logerman attending.
And so I I presented part of my
PhD protocol. I remember a couple of other
people, someone else presenting about the utility of
listening to wet voice,
and professor Logerman
(26:15):
stood up and basically told us we're all
wasting our time.
That why would you do anything other than
video fluoroscopy?
And I remember feeling just so completely deflated
at the time and and walking out and,
you know,
reconsidering my life choices, shall we say, from
an academic and professional,
(26:36):
perspective.
And
it wasn't until a number of and and
I'm I stayed in touch with her, actually.
She's such a lovely lady and very generous
with her time. Very strict, very you know,
like, you needed to know your stuff.
But after I'd completed my PhD and gosh.
It was probably it was a number of
years later and published a number of things
and started doing training
(26:57):
where I caught up with her afterwards. And
she emailed to say, do you know it
was a bit harsh? I think there probably
is some utility to it.
And so that that was really nice,
you know, as a as a an experience
to have that kind of tied off at
the end if you like. Yeah. I I
think we all have our experiences where we
stick our stake in the ground and say,
(27:17):
best yeah. I was like that with fees
for the longest time. Like, this is the
best thing in the whole wide world and
everything else, we don't need it, you know.
And and I had to I had to
soften that approach because I truly didn't feel
that way. I just was very passionate about
the tool that I had access to, you
know. So Yeah. Yeah. Yeah. I think as
we get older and more experienced, we realize
that all of these play a role in
in all of the things we do.
(27:39):
Exactly. That's exactly right. And, you know, you
you'll use the best tool at the time
for what you have and and what's available
to you. Yeah. Yep. Alright. Well, thank you.
Thank you so much, Julia. I really appreciate
this conversation. I think this is just it's
it's eye opening, but it's also comforting to
know that, you know, this this was a
tool that was very valuable for a long
time, and and I think just the the
(28:00):
proper
training and education
is really the key with all of this
stuff. So thank you. Thank you. Thank you.
Thank you. Thanks so much for the opportunity,
Theresa.
And that's a wrap for this episode. As
always, thank you so much for listening.
If you'd like to download the show notes
from this episode, please visit swallowyourpridepodcast.com.
There you can also sign up for our
(28:21):
email list so that you'll never miss another
episode.
If you do like what you hear, then
please subscribe and leave a review on iTunes,
or or share it on social media with
your friends and colleagues, because that is what
keeps these episodes coming.
If you'd like to be a guest, share
feedback, or request a topic to be discussed
on the show, please email podcast@TeresaRichard.com.
(28:43):
Thank you so much for listening, and we'll
catch you next week.
Popular Podcasts
Stuff You Should Know
If you've ever wanted to know about champagne, satanism, the Stonewall Uprising, chaos theory, LSD, El Nino, true crime and Rosa Parks, then look no further. Josh and Chuck have you covered.
Dateline NBC
Current and classic episodes, featuring compelling true-crime mysteries, powerful documentaries and in-depth investigations. Follow now to get the latest episodes of Dateline NBC completely free, or subscribe to Dateline Premium for ad-free listening and exclusive bonus content: DatelinePremium.com
The Bobby Bones Show
Listen to 'The Bobby Bones Show' by downloading the daily full replay.