Why I am an Audioprosthologist

Occasionally a patient comes along that really challenges me as a practitioner and requires me to reach beyond the everyday tools and prosthesis our industry provides and enter into the arts and craft realm of our profession, where normal assumptions and protocols no longer serve and require me to stretch in order to best serve my patient.  

Such is the case of, we'll call her Mrs. L for privacy sake.  I was first introduced to Mrs. L. by answering a call on the Saturday morning after Thanksgiving last year.  She explained that she had moved back into the area after having been living in the center of the state for some years and that she normally dealt with the audiologist associated with a local Otolaryngologist  she went to for control of chronic infections in both ears.  She furthered that she could only hear with one ear, due to the continued infections since her youth and that she needed a powerful hearing aid on the ear she could hear with and this was no longer working properly, but mostly just squealing loudly.  

She told me that when she tried to get service from her doctor's audiologist, she had been told they had no openings for over two weeks and asked me if I could help.  As I was forwarding my office calls to my cell phone and in my backyard garden, I advised that while not normally open, I could be able to meet her at my office in about a half an hour if she needed and that I'd be back in the office on Monday morning at 9:30 otherwise.  She allowed that Monday would be soon enough and I went back to turning my back bed, thinking no more about it until she walked into my store on Monday.

A spry, petite and silver haired octogenarian she appeared in my office with a large power behind the ear  instrument on her right ear, coupled to a full shell, un-vented soft mold, in an actively draining and sore ear.  And, as she described earlier on the phone, her aid was mostly just emitting a loud squealing noise, that those of us familiar with such, recognize instantly as feedback.

After making her and her husband comfortable in my lab, I asked her to take the aid out and allow me to inspect it.  I couldn't help but notice her wince in discomfort as she pulled the aid off and the mold from her ear.  A quick inspection revealed that the tubing had become shrunken and hard, with the squealing   coming from a crack where the tubing entered the mold.  Changing the tubing instantly solved the squealing problem, but not the discomfort being caused by her mold.

A few questions revealed that she had been fit by another audiologist in central Florida, before she had moved back here and that she had worn hearing aids for many years.  She also forwarded that the mold she was wearing had always been uncomfortable, hard to insert and remove, but  that she didn't know what else to do as she was functionally deaf without the aid.  So she believed she would just have to endure it, if she was to be able to understand her new husband.  (That's right an octogenarian newly wed.)

I asked her if I might be able to help, if she would be interested.  After obtaining her consent and following infection control protocols I had her again remove her aid and did a thorough otoscopic exam, which revealed drainage and evidence of ongoing infection.  She provided that she was under her local ENT's care for the infection and that he had advised her to leave the aid out to allow for air flow to help dry up the infection, but when she did, she simply couldn't hear.

After receiving her permission, I went to work on her mold.  Though the material is soft, the nature of it pulls or rubs soft skin during insertion and removal and when done dry and without lubrication can, in and of itself, abrade a blister.  This mold had been made with the idea of completely occluding Mrs. L's ear, in the belief that such was needed in order to reach her sensation levels without feedback.  And, while achieving that goal, the unintended consequences were that an ideal culture environment had been created behind the mold and in the space between it and her ear drum.  Her outer ear structure was so soft, that his mold painfully distended it while inserted and rubbed painfully upon insertion and removal, as well as causing uncomfortable baro-trauma due to the toilet plunger effect.

Hard to work with, the soft mold material yields not so much to cutting using the diamond bits and polishing wheels we use on hard materials, but rather by being burned off using a coarse stone.  Drilling requires starting with tiny burs and working up to the size desired using successive bit changes, lest the material split and  you ruin rather than effectively modify a mold.  Modification is a slow, rather messy process that produces the occasional puff of white smoke some often pungent aromas and amazing amounts of statically clinging particles that get flung off from the process that are difficult  clean from the equipment, mold, hands and work area due to their innate clinginess.

Within about thirty minutes I'd achieved a fit that included removal of the entire top half of the mold, including the helix area, addition of a four millimeter vent, shortening of the canal length and removal of material from the apex of the first bend in her ear.  After dotting with a drop of Miracel, Mrs. L. was able to easily insert, remove and wear her mold.   We found that her aid operated just fine at her use level without the least bit of feedback squeal.

I was rewarded not only monetarily for my repair and modification, but by a huge smile and tears welling up in her eyes, as she told me how much better it felt than anytime since she'd had it.

After seeing that we weren't having any trouble reaching her use levels with the modified and vented mold, I asked if she might be interested in something more comfortable, if it would work for her, and showed her a GN ReSound Dot.  She was intrigued by the possibility, upon seeing the huge size difference between her old aid and the Dot and asked how we might go about her trying one.  I advised her to return to her ENT to obtain a copy of her records along with his clearance to proceed.  She indicated that she would and we set a date for her trial fitting.

I ordered a GN ReSound Dot2 360 with a power receiver for Mrs. L. and awaited her return not really knowing whether it would work for her or not.  Truth is, she was more excicted about the possibilities than I was and I began to think about the possibility that I had created unreasonable expectations in my patient, but decided not to worry about it until we saw how the trial fitting worked out.

When she returned Mrs.L presented me with her most recent audiogram, it indicated a pure tone average for her better ear of sixty-three, air conduction and fifty-three for bone conduction.  Her left ear indicated a pure tone average of one hundred and seven, for air conduction and fifty-three for bone conduction.  She also expressed amazement at how much more comfortable her old mold was and that she could now wear it for hours without the usual headaches that normally accompanied extend wear.

I entered her audiometric data into the programing interface, connected a power receiver and then chose and installed a split dome tip and placed it upon her waiting ear.  Following calibration for feedback control we began the process of fine tuning.  Immediately Mrs. L. commented upon how comfortable it was and how natural her own voice sounded.

Following the fine tuning and after going over the instrument's operation, maintanence and such I programmed and disconnected it and went about righting up a trial fitting agreement .  This agreement would allow Mrs. L to take the instrument home, go about her routines and put it into the environments that she needed it to work in before I asked her to pay for it.  If, the instrument didn't work for her, she simply had to bring it back, without incuring any obligation, or she could pay for it anytime within thrity days if she wanted to keep it.

I scheduled a routine follow-up for two weeks and instructed her to call me immediately with any problems, issues or questions, should she have them, and otherwise I'd see her in two weeks.

After she had left, I began to look more closely at her left ear.  While the air conduction scores were in the profound loss range, the bone conduction sensitivity was the same as the right ear, in the moderate range.  I started to envision how we might possibly fit her left side, thereby giving Mrs. L the sensation of stereo listening once again, with it's potential for better localization and understanding in those more complex sound environments where she was having her most difficulty and decided to pursue the idea further.

I had been exposed to a couple of nitch manufacturers who were promoting a bone conduction in-the-ear hearing aid and I had seen presentations where other manufactures had solidly embedded a power receiver into a custom earmold and achieved some success, so I called ReSound and asked if they had any such product.  Sadly, they did not, but the idea intrigued the manager of their mold laboratory, Mr. Steve Ketchmark and we discussed the potential at some length.

Upon returning for her check up, Mrs. L reported that she was doing very well,  so well she paid me.  But, felt she would   achieve even better results with a custom mold for her fitting.  I advised that prudence and good practice dictated that due to her ongoing infections and the fact that she was still under her ENT's care for the last flair up, that we obtain his clearance before we took any impressions for a custom mold.  I also discussed with her the things I'd been pondering regarding the potential of fitting her left ear.

I explained that this would not be a normal fitting, and that it woud require me to work with the manufacture to actually craft something that they didn't have.  But, if she would like to explore the possibility I would be willing to proceed upon the same trial basis used for the other ear and that if, she didn't find the benefit, she wouldn't have to pay for it.

Given our previous successes she instantly agreed and reported that she had been back to her ENT post our fitting and shown him her new Dot and bragged up the differences in care.  I couldn't help but smile and get the warm fuzzies.  We agreed that prudence would rule and she would wait for the impression for her custom molds to be taken until after her doctor cleared her and she advised she would be in touch as soon as she saw him next.

I received my next call from her shortly after the first of the year and she advised that her doctor had indeed now issued her clearance to allow for me to make her some custom molds, so on the seventh, I forwarded a pair of impressions to Steve at ReSound, the right to be made into a regularly vented power micro-mold the left, a hard Lucite type material, I hoped to turn into an adequate bone conduction oscillator.

I began the process by stripping all of the retention and sound dampening material from the can of the receiver.  In a normal fitting, this material would be serving a shock absorption role, actually preventing the vibrations created by the receiver from being transmitted to the mold they are seated into.  However, in this case I wanted the exact opposite effect.  I wanted as much of the internal vibration of the receiver as possible to be transmitted into the mold, as it would be those vibrations that I was counting on to achieving any results we might enjoy through this fitting.

Next, I filled the sound port in the custom mold  ReSound had made with UV paste, cured it then polished any burs smooth.  The next step involved filling the remaining cavity in the mold with UV paste, then suspending the cleaned can of the receiver into the paste and curing it in such a way as to avoid getting any voids or bubbles into the mix.  Lastly, I pulled paste over the outer end of the receiver until the wires were completely embedded and cured.

Last week, Mrs. L experienced a flair up in her left ear that left it sore and tender, putting off our trial till Wednesday of this week.  When she came in, we found that there was still a sore spot on the bottom of her canal, just  outside the first bend, but she wanted to proceed anyway, and had come from seeing the doctor earlier and received his blessing to proceed.  Given this we proceeded by polishing and removing material until she could easily insert and wear the mold and instrument without discomfort.

Now, to find out if it was worth all the effort.  I hooked both her instruments to the program interface and turned on the aid.  Nothing.  She couldn't tell any difference at all.  I turned and reset all the outputs to maximum on the screen.  Still nothing.  Disappointed, we were beginning to think that our noble efforts were going to be for naught, when I noticed that the numbers on my display just didn't look right.  I should have been able to get over twenty dB more of gain than what I was seeing.  So I started to look closer.

It was then that I noticed that the instrument was still set up for a regular power receiver and was therefore limiting the output to what it was capable of achieving, not the power one that I had installed.  I returned to my set-up screen and reconfigured the aid for the receiver I actually had on it, then returned to the calibration and fine tuning screen and muted the right aid.

In a normal tone of voice I asked, "Is that any better Mrs. L?".  Her answer surprised me.  First she said no, she didn't think that was any better either.  I explained that I had turned off her right ear, the one she normally heard with and was talking to her through her left ear and given her loss, if she was hearing me at all, it was from the left ear.

To further demonstrate, I removed the right aid from her ear completely and again asked her how she heard me?  This time, she asked if I was speaking in a normal tone of voice?  To which I replied yes and asked her husband who was seated approximately six feet behind her to say something.  He asked if, she could hear him, to which she answered that yes she could.

It was then that I noticed the tears welling up in her eyes, as she realized that she really was hearing out of an ear she had been told for years was dead and useless.  That she was in fact carrying on a normal conversation using this "dead" ear.

Now, this fitting is still in the "trial" stage.  I wrote an agreement that will allow Mrs. L a generous discount from our list price, but will still allow for me to be well paid, should she decide she is receiving benefit from this new fitting.  I haven't been paid in dollars yet and in the end, she may not see the value that we are asking for what we've done.  Still, whether she keeps this fitting, or returns it, she reminded me of why I am an audioprosthologist and through her tears of joy at being able to hear again,  has already paid me in ways others will never know.

R. D. Taylor, Audioprosthologist,

And, today, feeling pretty good about it.

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Value Added

As a hearing health care professional with over twenty-five years experience in the dispensing field I am constantly reminded that I AM the value added to each of my fittings.  If, I do my job well someone will hear better and have a more harmonious life, with fewer tensions and misunderstandings.

Much of my job involves listening, letting my patients explain in their own words what they are experiencing, what they expect from their anticipated dealings with me and what their budgetary constraints are.   Some aspects of my practice involve taking detailed measurements of what my patient's  currently hearing levels are for use in programing their anticipated hearing instruments.  Other aspects involve examination of their ears and the actual physical fitting of each instrument to their individual ear.  Still other duties involve listening to their experiences in their own acoustic world and then adjusting for comfort, clarity and transparency.  Part of what I do deals with patient education; about their hearing, loss, the equipment we've chosen for them and how they are to use and maintain it.  And, lastly I must be there to service their maintenance needs and keep their aids in their ears and out of the shop as much as possible.

At each step, if I'm performing on my patient's behalf, I add value to that fitting and it is this added value that makes up the difference between what I purchase the hearing instruments I fit for and the price I charge to fit them.  This value added covers my costs of doing business and hopefully enough profit to live a comfortable life style.  It is this same added value that keeps my practice growing with referrals and repeat customers.

Now, I understand that any corporation's officer and board are there to increase their shareholders' yield and stock values and that healthy companies and good management do this through the value they add to the goods and services that they sell to their customers.

So, that is why I ask an open question of the upper management of my industry, particularly the boards and CEO's. who have decided that they as managers add more value to stockholders through different means.

How do you think the folks actually dispensing your product and representing your company to the public feel when you make the management decision that you as the leaders of your company believe you bring more value to your stockholders by selling the company, than by selling the company's products?

I'd like to hear from any of you out there with a response.

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R. D. Taylor, at large.

Open letter to Michel Steele, Chairman National Republican Party

Michael Steele, Chairman
National Republican Party
310 First Street, S.E.
Washington, DC 20003

R. D. Taylor
Palm Bay, Florida 32905

24 January, 2010

Dear Michael:

I’ve been getting quite a bit of mail from you and the party of late addressing me by my first name and acting like you know me, and wanting me to participate in this great battle you describe.  I understand from your entreaties just how much you would like for me to open my wallet and provide those funds for your use for more of the same.

The problem is, that you and our party are so terribly out of touch, have strayed so far into the hands of the religious right and have totally sold out the small businessman or woman to Wall Street, big Pharma, the Insurance industry and big Oil, that you’ve lost your way.

Your letters and simplistic surveys and censuses don’t seek to find out what we are really going through, or inquire about how we might better things, they are written and presented in such a way as to simply reaffirm the party views and ideas you’ve already decided.  They have become insulting to our intelligence in their forgone construction and form.

There doesn’t seem to be much our party can do except to make sure those nasty Democrats aren’t able to do anything.  How totally en genius!  Just blame everything on Obama and the Democrats.   Yet they came to power because our party simply doesn’t get it anymore.

On health care, our party has played nothing but spoiler.  Refusing to support anything excepting more of the same lining of the pockets of the insurance establishment, pharmacological companies, hospitals and medical establishment.

You would have us all believe that if we established a single payer system, that the world would end, that we would loose all control over our health care, with Washington bureaucrats making all of our health care decisions for us.

Yet, you totally refuse to acknowledge that under the current system we already have bureaucrats making our health care decisions for us.  It’s just that now those bureaucrats work for for-profit insurance companies HMOs and Hospitals.

The party refuses to point out, or even reccognise that all those lobbying dollars you and our other politicians from both sides of the aisle  so eagerly accept from this entire industry, come from the skim off dollars paid for health care, diverted to profits, the insurance company’s profit and via their lobbying contributions to political parties and candidates, your profit. 

You won’t even acknowledge the fact that their profits are a direct result of them withholding as much of the premiums paid as possible while paying as few benefits as possible.

Our law continues to allow this whole industry a total exemption from anti-trust regulation, allowing them to collude openly over benefits, premiums and payment structures throughout the entire industry.  Yet, the same regulations they are exempt  from, would make me a Federal Felon if I even mentioned pricing structures over a dinner with colleagues.

So instead of meaningful debate on real issues, our party promotes the “Death Panels” myths and the notion that all of a sudden we won’t have any control over our own health care.  Just how much control do you think we have now Michael?  How about those of us at middle, or like me, preretirement age, all of us with some sort of preexisting condition trying to get health insurance? 

But, let’s not dwell too long on health care, let’s move on to the economy and it’s current state.  Michael continuing to blame the Democrats for this mess is just plain a lie.  The final nail in Glass-Spiegle’s coffin was placed there by a Republican congress, ushered through by none other than your old friend Phil Grahm from Texas. 

Is your memory getting any better now Michael? 

It was Phil’s bill that removed the final barrier to Banks, Insurance companies and Brokerage houses mingling and merging funds for their own profit and amusement.  Oh and Mr. Greenspan was more than happy to allow that those regulations were no longer needed due to the vastly improved “risk management” that the markets allowed. (Yea, they were all set off against credit default swaps sold by a company without the reserves to pay even 1% should any turn bad, AIG.)

Isn’t Mr. Giethner a Bush appointee?  Hey didn’t his old banking and brokerage buddies  make out nicely in that AIG payout on their paper?  You just can’t get better than 100% on the dollar for otherwise worthless paper, from a bankrupt company now can you?  Oh, you did know that those were taxpayer dollars being paid out didn’t you Michael?

Yes, even the “Bailout” happened on Mr. Bush’s watch now didn’t it?  Oh, and it was Republican appointees heading up all those watchful regulatory agencies now wasn’t it Michael?  Come on, now a little honesty just might help you regain some of the respect you and our party have so richly lost.

And, while we are on the subject of Mr. Bush’s administration, wasn’t he the one who so greatly expanded the federal agencies of “Homeland and Transportation Security”  giving us a whole new layer of Federal expansion into our everyday lives?   And, plunged us into war on two fronts by using fear and distortions of intelligence and out right lies to get our support all for the total illusion of security. 

I say illusion Michael, because even with all our loss of civil rights, armed guards, airport screening and extra security, another terrorist got on a plane with malicious intent and who thwarted him?  Fellow passengers Michael.  The very passengers who are all treated as though they were terrorist just to get on the plane.  Not the massive intelligence apparatus, nor the self important screeners, nor any of our government’s efforts prevented his boarding.  Yet, plain old citizens were the ones who jumped in to thwart his evil deed, not all the billions spent, nor phones tapped, nor suspects tortured thwarted this terrorist, but rather normal citizens, acting freely, in their own best self interest.

Yet it was this “Faith Based” president and his administration who, after 9/11 never acted in faith again but, always out of fear.  It was this unalloyed fear that was played so beautifully to get us into Iraq and Afghanistan.  It is fear rather than faith that would have us swap our personal freedoms and constitutional protections for the total illusion of making us safer.  And Michael, a Republican President and Vice President who spread such fears and who’s administration threw out the rule of law and just made up their own rules to suit the mood.  Let us not forget that it was this administration that gave us David Chew, who characterizes semi-drowning someone as “enhanced interrogation”

Yes Michael we are the party of torture, Guantanamo and indefinite detention without charge, or trial.   And all those mercenaries that Mr. Bush and Cheny hired to fill in where our men and women in uniform couldn’t in their global adventures, have given our country a very well deserved black eye, while arrogantly operating outside any law, but their own,  killing anyone in their paths and lowering our esteem  as a nation in the eyes of the whole world.

I’m sure that it will be a very easy step to “privatize” security for the next national emergency, hurricane, flood or such and just call in the men and women of Xi, or whatever they have morphed into and let them handle it.  Far easier to just call them and write the check than call out the national guard.  Oh wait, we can’t call out our Guard, they’ve already been called up and are in Afghanistan, or Iraq filling in those holes in our game plan that regular Army can’t, because so much money has been funneled to “private security”.

How would you feel about such “private security” forces handling traffic control around your home in times of disaster Michael?  What with their demonstrated immunity and ability to use whatever force they deem appropriate and the only demonstrated check being that they will have to change their corporate name to get the next government contract?

Now, let’s move on to the party’s social agenda, which best  I can tell from your mailers is like this:  Every kid has prayers in school everyday before class, no one can get an abortion, marry who they want, research what they think might be important, or burn a flag. 

Seems more a religious agenda than a proper political one.  Any move toward more church involvement with the party places the party’s agenda in someone’s doctor’s office, bedroom or school.  Your total pandering to the Christian right with their absolute knowledge of what is right and wrong, for everyone, continues to allow for governmental creep and overreach into our daily lives.

Now, let’s discuss our parties last Presidential ticket.  John McCain is a fine Senator, a true war hero and would have made an acceptable choice.  In fact he was my choice all the way up and until about a week after he’d made his choice of running mate.  Then you lost me.  When I saw the footage of Mrs. Palin’s interview where she was asked the incredibly soft ball question, “What periodicals do you read?” and instead of answering anything, she simply got a blank look and started rambling, I knew we as a nation could not afford to have this woman a heartbeat away from being our commander and chief.

And, sadly, that McCain had made this choice, seriously called into question what head he was thinking with, thus making him unacceptable for the role as well.

And, while we are on the topic of Mrs. Palin, did you happen to catch the video of Glen Beck's interview with her? 

On the other hand, had the V.P. selection gone to our former Secretary of State, Dr. Rice, that decision would have demonstrated in a stroke that both were up to the task, taken the race advantage from Obama,  and earned my vote.

It’s not that I don’t admire any woman who can gut her own moose kill, it’s just that I don’t see that in and of itself as, qualifying one for the second highest position in the nation.

As to what our party should stand for; whatever happened to actual limited government, defending an individuals rights under the constitution?  All of our rights Michael, not just the ones that make the religious right feel good, like the freedom of worship, even if it isn’t what you, or they believe?  Protection from unreasonable searches and equal protection under the law (find a TSA or Homeland Security officer anywhere who can even imagine an “unreasonable” search.)?

What about defending an individual’s right to their own idea of the pursuit of happiness?

What is it about defending an individuals right to the “pursuit of happiness” makes the party uncomfortable Michael?

Is it the point about letting individuals decide for themselves, instead of the party, clergy and then by extention government deciding for them? 

You would scare us all silly about those evil Democrats and what they are trying to do to us, yet the biggest expansion and grab in decades came on Republican watch.  The dismantling of the regulations that were meant to safeguard against the very debacle that occurred on Wall street were put forward and passed by Republicans.  The regulators, top to bottom who were asleep at the switch with everything from Credit defaults to the Bernard Maidoff Ponzi scheme were all either Republican appointees, or were overseen by Republican appointees.

Yet Michael, you continue to beg me to support this party with my contributions, without acknowledging just how far this party has strayed  and how much damage elected Republicans caused in the last couple of decades.   Now, with last weeks Supreme Court decision and all that cheering coming from almost all of our elected Republican law makers about free speech, all the while dancing  dollar signs jigs, in anticipation of those new corporate contributions about to start flowing Michel,  I've already got the best party and politicians that money can buy.

So, frankly the answer isn't just no, until the party reaffirms and realigns itself with less government, small business,  more personal responsibilities, greater personal liberties, and an absolute protection of the entire bill of rights and the rule of law, the answer is hell no!

Very Truly Yours,

R. D. Taylor

Getting started

This is a project I've been mulling over for some time. Though I've written various things for years, some published and some not, till recently there wasn't any place to easily aggregate the various thoughts, ideas and such into a central place. Well this blog will provide that format and for those who wish to join my journey I say welcome.