The week’s Hearing International is prepared by guest author Shelley Moats, Au.D.  Shelley describes her motivation for her interest in pediatric audiology as well as the benefits of becoming Pediatric Audiology Specialty Certified by the American Board of Audiology.    Shelly works with children each and every day at Little Ears Hearing Center at Open Arms Children’s Health in Louisville, Kentucky- USA- RMT

——————————————————————————————————————

I have been practicing audiology since 1996, and started out as a “jack of all trades”– seeing patients of all ages, providing a variety of diagnostic services, and fitting hearing aids to patients of all ages. Early in my career, I developed a strong interest in working with children with hearing loss and their families. While I had some opportunities to provide this service initially, I did not begin to exclusively see children until a job change in 2005 led me to an exclusively pediatric position. I was excited for this change as my desire to become a pediatric audiologist had blossomed significantly, and my caseload had shifted in this direction naturally over time along with my interests.

 

Pediatrics

In 2005, I took a position in a university setting where I was not only providing pediatric audiology services, but teaching Doctor of Audiology (AuD) students to provide best practice services and interventions. It became clear that “pediatric audiology” meant different things to different providers. We worked hard as a faculty to impart the need to adhere to guidelines published by our professional organizations, but our students reported that procedures were not consistent across their clinical placements and 4th year sites. In addition, we had the task of teaching our students that good pediatric audiology was not strictly about audiology. We function as case managers, make referrals to other healthcare providers, help parents deal with their emotions when their child is diagnosed, advocate for educational services for our patients, help families find funding for devices … the list is endless.
The scope of knowledge that is required to care for kids with hearing loss is immense. As I branched out started a non-profit pediatric audiology practice on my own, and then successfully merged this practice with another pediatric non-profit organization, the need for quality audiology services for children remained apparent. Children are not little adults, and the skill set required to take care of their hearing needs is completely different. Until recently, there was no mechanism in place to ensure that providers have the knowledge to take care of this population.

 

Certification

In 2011, the American Board of Audiology (ABA) introduced the Pediatric Audiology Specialty Certification, or the PASC. This came on the heels of a successful implementation of a specialty certification for cochlear implants. I was pleased that a group of experts in pediatric audiology had come together to develop a standard for what pediatric audiologists need to know, and contemplated taking the exam for a couple of years. I wanted a way to measure my own knowledge, and take a look at areas where I could improve. I finally decided to apply, and sat for the examination in 2013.

The PASC, like other ABA credentials, is voluntary. In order to apply and sit for the exam, you must be a licensed audiologist with a minimum of two years of post-degree professional experience. Of that work experience, 550 hours must be in pediatric audiology, with another 50 hours in pediatric case management. I completed the PASC application (Fill one out here), downloaded the list of suggested study materials, and got to work.

The content areas evaluated by the PASC examination include:

• Laws and Regulations• General Knowledge of Audiology• Child Development
• Screening and Assessment Procedures
• Counseling
• Communication Enhancement Technologies
• Habilitation/Rehabilitation and Educational Supports

I spent a reasonable amount of time preparing for the exam, focusing primarily on areas that I didn’t use frequently in day-to-day patient care. For example, as a clinic-based audiologist, I needed to review some educational audiology concepts that I don’t use as frequently, such as how to complete a classroom survey.

Exam day came and I was surprised by the comprehensive and rigorous nature of the exam. The ABA partners with subject matter experts in pediatric audiology and with HUMRRO, a leading psychometric organization, to create and validate test items. The result is a comprehensive, statistically valid examination that allows demonstration of knowledge and expertise in the area of pediatric audiology. When I received notification that I passed the exam, I also received a breakdown of how I scored in each of the areas described above. This was a useful tool to identify areas of relative weakness, and allowed me to focus on improving my knowledge in these areas through continuing education opportunities and independent reading. In addition, ongoing continuing education is required to maintain the PASC that is well beyond what is required for a state license; there is also a minimum number of hours that must be obtained in pediatrics, a Tier 1 requirement, and an ethics requirement.

 

Benefits

I took the exam initially as a yardstick to measure my own performance. However, I have been surprised at how well the PASC has been received in the medical community and among families of children needing services. When I received the certification, my practice notified all local pediatric providers to share information about the credential. We received positive feedback from many referral sources, and gained some new ones in the process. Simply put, pediatricians and other referring providers want to ensure that their patients are receiving the best possible care from the most qualified professional.

Other healthcare providers have a clear understanding of the rigor that is required to prepare for and pass a specialty certification exam, and having this certification has had an impact on referral patterns.

Our families were excited as well – some reported that they saw our PASC announcement posted at other healthcare offices! They were happy to know that their child is receiving services from a provider that has taken that extra step to demonstrate their knowledge, and is committed to ongoing education.

 

Guest Author:  Shelley R. Moats, Au.D., PASC

Dr. Shelley Moats is the Director of Audiology with Little Ears Hearing Center at Open Arms Children’s Health in Louisville, KY. She is the only holder of the PASC (Pediatric Audiology Specialty Certification) in the state of Kentucky. Dr. Moats is married to “the other Dr. (Troy) Moats”, and they have two children, Lily and Hayden. She enjoys attending her children’s many sporting events, a good book, and long walks with the family dog Lacey. 

This series of posts at looks at Hitler’s hearing impairment. This is the third posting in the series and it is certainly not a tribute to Hitler, but an interesting discussion of a hearing loss that was accumulated over a lifetime by an historical figure. This series is a re-visit of a topic that was first discussed at Hearing International August 27-September 10, 2013. While much of the content will be taken from the originals, components have been added in this visitation of Hitler’s Hearing Loss. At the end of this 3-week series, there will be an estimate of his likely hearing impairment. 

While history will never know the extent of this impairment, there is evidence that can be compared with what we know today that gives us clues as to the extent of his hearing impairment. Did this have any effect on behavior? Did this cause miscommunication among trusted generals and others? Other issues? At the end of our discussion …you decide….RMT


h31.jpgOur discussion of the bombing last week brings Hearing International to the question of how  Hitler could have survived a blast from a kilogram of plastic explosive when he was only 6-12 feet from the bomb?  This question has baffled those who have studied the July 20, 1944 plot for over 70 years. While there has been a great deal of speculation as to how he survived the blast, Hitler felt he was simply being protected by providence, as this was only one of many attempts on his life.  There is even speculation that Hitler actually died in the July 20, 1944 attack and that he was impersonated by his body guards or doubles during the last months of the war.  Although probable, it is highly unlikely that in the past 70 years someone would not have come forward with the truth, especially during the Nuremberg Trials,in an effort to save their skin. 

Deep in the forests of Rastenberg, Germany (now Poland), Hitler’s new Rastenberg or Wolf’s Lair Headquarters (see map below) on the Eastern Front consisting of intensely guarded buildings and bunkers, Hitler rescheduled his July 20 staff meeting for 12:15pm as he was supposed to meet Mussolini that afternoon.

 

 

The meeting was normally held in a bunker without windows and built with very thick walls called the Führerbunker but, as indicated last week, the meeting was unexpectedly changed from the subterranean Führerbunker to Albert Speer’s wooden barrack-hut  because of the hot weather. This drastically changed the blast intensity as the wooden barrack had open windows of much less rigid construction than the Führerbunker.  The diagram below presents the positions of various individuals and the bomb (in red).  While Stauffenberg originally placed the bomb to the left of the table leg, another officer moved it to the right of the table leg; that, and the fact that Hitler had a habit of almost laying on the map while looking at troop movements, probably sheltered him from the major portion of the blast.  

 

When the blast happened, the four officers on Hitler’s right, positions 2,3,4,5 were killed, while Hitler, position 1, and two officers to his left, positions 23 and 24, were virtually unhurt, and two officers to their left, positions 22 and 21 were wounded.  One look at the room (photograph above) suggests that if the bunker had been used, all of the people in the room would have died from the blast.  While Hitler’s private physician removed 150 splinters from Hitler, there was also blood coming from his ears.  Reports from the scene and Hitler’s personal physician suggest that he probably suffered an acoustic trauma created by the blast.

 

The July 20, 1944 Explosion 

 

When a bomb detonates, the energy released from the explosion radiates outward in all directions at once at speeds between 3 and 9 km per second. As this sphere of energy HIII3expands, it compresses and accelerates the surrounding air molecules into a supersonic blast wave. This overpressure only exists for a few milliseconds, but it is the primary cause of explosive injuries and property damage. The closer to the source of the blast, the more severe the compression. Hitler was only 6-12 feet away from the blast.  In an explosion, the initial concussive force of a blast wave is immediately followed by high-velocity shock waves that impart more energy into whatever they’re passing through, HIII5be it a concrete wall,  one’s vital organs, or a wooden table containing maps during a staff meeting.  As a blast wave passes over an area, it leaves literally nothing behind. The supersonic wall of air leaves a near-perfect vacuum in its wake.  So,  a split second after the body is severely compressed, it is subjected to an equally massive opposing depressurization force.  Unfortunately, the explosion isn’t over yet, as air immediately rushes in to fill the atmospheric void left behind by the blast wave, pulling debris, objects, and people back towards the source of the explosion. This blast wind is strong enough to hurl a human body several meters. Those caught by the blast wind while standing up are the most vulnerable to being carried away. But it isn’t this blast wind itself that injures—it’s the blunt-force trauma resulting from face-planting into the side of a Buick at freeway speeds.   This barotrauma wreaks havoc on the innards, especially air-filled organs like lungs, ears, and stomach, as well as joints and ligaments where tissues of differing densities meet. This often causes hemorrhaging, and it may even result in organ rupture. The lungs are especially at risk of hemorrhage as well as edema (swelling brought on by fluid buildup).  The brain is not much better off.   Recently military physicians studying the effects of barotrauma on US Armed Forces have compared the effects of an explosive blast on the human body to the act of squeezing a tube of toothpaste—blood and bodily fluids are forced into the brain and skull, resulting in edema. The Picture at right is the staff brieHII10fing room at Wolf Lair after the July 20, 1944 assassination attempt.  (Click on the “Hitler Bomb Plot” picture for a short video of the devastation created by Stauffenberg’s bomb).

 

Hearing Loss from Explosions

 

  According to Otolaryngologists at the US Army Surgical Institute at Ft. Sam Houston,  tympanic membrane perforation is the most common primary blast injury based upon a retrospective study of US service members injured in combat explosions in Afghanistan or Iraq and treaHIII4ted at Ft. Sam Houston between March 2003 and July 2006.   Their results in the evaluation of 463 wounded patients indicated that 15% of the patients had a  tympanic membrane perforation. A total of 97 tympanic membrane perforations occurred among 65 patients (see left). The average surface area involved was 41% and more than one third of the perforations were central or anterior-inferior. Most (83%) patients reported symptoms, most commonly diminished hearing (77%) and tinnitus (50%). Outcome data were available for 77% of perforations with 77% spontaneous healing occurred in 48%. The remainder (52%) had surgical intervention. The most common audiogram abnormality was mild high frequency hearing loss.  Tympanic membrane perforation occurs in 16% of explosion injured patients. Most patients are symptomatic and many have large perforations requiring operative intervention.  An explosion causes a large amount of energy to be displaced, creating a shock wave and a very loud sound. This loud sound may be powerful enough to destroy a person’s ability to hear, either temporarily or permanently.  A 2012 effort to review noise induced hearing loss from blasts by Dr. John Oghalai, Associate Professor of Otolaryngology, Stanford University suggested that when we looked inside the cochlea, we saw the hair-cell loss and auditory-nerve-cell loss,” Oghalai said. “With one loud blast, you lose a huge number of these cells. What’s nice is that the hair cells and nerve cells are not immediately gone. The theory now (2012) is that if the ear could be treated with certain medications right after the blast, that might limit the damage.”  This, however, was certainly not available in 1944.  

 

Hitler’s Hearing Loss

 

Hitler was very close to the blast.  His physician noted blood from his ears right after the blast and for some time afterwards, suggesting tympanic perforation (described as shattered eardrums in the literature) and he was treated by Dr. Erwin Geising, an ENT whom Hitler had seen for a reoccurring furuncle over the years; however,  he did not record much other information about the specifics of the impairment and the residual impairment created by the perforations.  Most audiologists realize, however,  that a  tympanic perforation can create no hearing loss or a maximum conductive loss of 40-60 dBHTL depending upon the frequency and the extent of the damage.  If one considers that the Fuhrer may have had some sensori-neural hearing loss from noise exposure in the trenches during WWI, then combining that with the blast perforations and possible acoustic truma, there is a real possibility that an existing sensori-neural impairment was significantly exacerbated.   

It is also well known that Hitler was given no less that 73 different medications, some routinely during the years 1941-45, by his personal physician, Dr. Theodor Morell (Pictured left). Morell kept a medical diary of the drugs, tonics, vitamins and other substances he administered to Hitler, usually by injection (up to 20 times per day) or in pill form. Some of them were Morell’s own mixes. His experiments sometimes contained toxic and addictive compounds such as heroin.  Later, historians speculated that Morell played a big role in Hitler’s deteriorating health. Some of the compounds given to Hitler and written in Morell’s diary were: atropine, caffeine, cocaine, adrenaline, morphine, testosterone, lipids derived from animal tissues and fats and many others.

While it is sheer speculation, based upon his noise exposure history and what we know of blast injury, it is possible to estimate Hitler’s hearing loss with a 75% chance of accuracy at 35-40 dB loss for the lows, and an 50+ dB loss for the highs in the left ear. For the right ear there would have to be some residual impairment due to Stauffenberg’s bomb on top of his noise induced hearing loss.  Thus, his impairment would have been much worse for the right ear, probably in the 70-80 dB level for the lows and 90 + for the highs. 

As audiologists we also know that hearing loss reduces a person’s interactions and social capabilities, which could be a partial explanation for why the Fuhrer was very antisocial and was seen in public very little from the time of the July 20, 1944 plot and the end of the war.  What ever the specifics of Hitler’s hearing loss, he probably had a significant hearing impairment at the time of his death, or if he did escape to South America as some suggest, for the rest of his life.  

 

References:

Health Day (2013).  Hearing Loss From Explosions May Be Treatable, Mouse Study Hints.  Plos One.  Retrieved January 12, 2018. 

History Channel (2018).  The Nuremberg Trials.  Retrieved January 10, 2018.

Irving, D., (2005). The Secret Diaries Of Hitler’s Doctor.  Focal Point Publications, London.  Retrieved January 12, 2018.

Radeska, A., (2016).  Theodor Morell was Hitler’s personal physician who was treating him with unorthodox medication.  Vintage News.  Retrieved January 12, 2018.

Ritenour, A.,  Wickley, A., Ritenour, J., Kriete, B., Blackbourne, L., Holcomb, J., & Wade, C. (2008). Tympanic Membrane Perforation and Hearing Loss From Blast Overpressure in Operation Enduring Freedom and Operation Iraqi Freedom Wounded.  Journal of Trauma, Infection and Critical Care.  Retrieved January 12, 2018. 

Tarantola, A. (2012).Could an Explosion Really Knock You Over Like in the Movies? Gizmodo.  Retrieved January 11, 2018.

Wikipedia (2018).  Operation Valkyrie.  Retrieved January 10, 2018. 

Videos:

BritishPathe (2010).  The Hitler Bomb Plot.  You Tube.com  Retrieved January 10, 2018.

You Tube (2016).  Adolph Hitler Escaped and Lived in Argentina / FBI Classified Proof.  Retrieved January 12, 2018.