The patient is imprisoned in a kind of limbo.
He can hear and see the world around him – voices talking, machines blinking, doctors moving around – but cannot respond. He’s in a vacuum.
But there is a lifeline. A fragile thread. “How are you today?” a voice says. The patient’s eyes open wide. His mouth works, but no sound comes out. “Frustrated…” he finally manages to say, in a weak breath.
His lips are carefully wiped with a water-soaked sponge. “When you have time do you want to watch some football?” The question is simple, but means so much more. It is connection.
That connection is a speech and language therapist, a specialist working in critical care. They help the most seriously ill patients, working in this eerie twilight zone between dark and light, silence and sound, providing the connection with life beyond illness.
The elderly patient we are with today has a tracheostomy – an incision in his windpipe that enables him to use a ventilator, alongside his nose and mouth, to support poor lung function after heart surgery. The loss of strength, especially in the muscles that shape voice and meaning, is deeply felt.
“Not being able to communicate and feeling thirsty are some of the things patients remember as most distressing,” the therapist says. “And not being able to communicate can have a huge psychological impact.” As she talks to him, she is gently feeling below his chin for an assessment of his swallowing skills.
As the same muscle group responsible for our speech, the muscles controlling our swallowing are vital to our health. If they don’t work properly, we may not be able to breathe, let alone eat, drink, or talk.
Speech and language therapists study this particular group of muscles intently. With seriously ill patients, the principal means of communication and how to support it, strengthen it, and get it back to a functional condition, is clearly a vital role. Perhaps surprisingly, as a critical care discipline, speech and language therapy is a relatively recent practice.
In fact the group I meet with have some from all sorts of backgrounds and from all over Europe – in the UK, and in our hospital in particular, the specialist field of critical care speech and language therapy is more advanced than in many other countries. Now the role is seen as so central to critical care that the team has nearly trebled over the last 15 years and could still happily recruit more.
“Because we are a cardiothoracic centre a lot of our patients are very complex,” one tells me. “We are very much part of a multi-professional team. We work closely with physios, occupational therapists, dietitians, medical and nursing teams and the psychology service. We feel very much part of their team.”
The team admit that when asked what they do for work, many interpret speech and language therapy as simply ‘helping people not to stutter’. Of course, that is an important part of the role, but there is so much more to it than this, not least its crucial place in critical care.
After a major illness or operation, it is the speech and language therapist who is often the first to engage the patient in conversation as part of assessment. Ensuring they can drink, and communicate, is crucial to successful recovery. Their mood has a big bearing on this too, as does having family there to give support. “Often the first things they say are ‘I love you’ to their family,” the therapist points out.
In extreme situations, where the voice has gone completely and even the arms and hands are too weak to help, a special communication chart is used, where eye travel alone can help to spell out words and meanings. This can be useful when, as happened recently for example, the team worked out that one patient was not hungry herself but was trying to find out if anyone had fed her cats.
Like so many roles in a hospital, it is this combination of knowledge, skill, and compassion in equal measure that helps the patient to recover. Today’s patient is asked to remember family names – a vital cognitive test – and to eat a small amount of food and fluids – important for assessing his swallow effectiveness.
He is even asked to try and sing a note, which enables the therapist to assess voice quality and airway protection . “Even when we are casually chatting we are watching them, making an assessment,” she says. “It’s so important for them to be heard.”
We finish the visit to the ward by checking in with the consultant. The two clinicians confer and swap notes. The patient has done well today, but is clearly in for a long journey to full recovery. It is on the way out though that the most telling comment is made.
Thanking her for her time, the consultant says to the therapist: “Oh, you’re more important than me.”