The Voice and its Power in Care
Since Intensive Care Week, we’ve been thinking about the different stories shared from the front line of intensive care, and while the week might be over, we know that care continues.
And so we’re continuing to share those stories. We asked Sarah Wallace OBE to tell us about a key issue she faces as a Speech and Language Therapist (SLT), and what keeps bringing her back to work. She shared the story of a patient who we’ll call Alistair, whose interaction with Sarah left its mark on her - on how she works and why she still shows up despite the intensity of the job.
By definition, my role means I only end up seeing patients who haven’t had a straightforward ICU recovery.
But the number of ‘straightforward recoveries’ seen across the UK’s intensive care units (ICUs) is falling. We are all familiar with the picture of increasing acuity, age and multimorbidity, which means more patients require prolonged ventilation and have more complex rehabilitation needs, making their recovery more challenging. Alistair was one such patient. Sarah met him one morning at Wythenshawe Hospital.
Alistair was in the cardiothoracic ICU, recovering after cardiac surgery. He had a tracheostomy, and had been on a ventilator for some time. When Sarah met him, he was visibly distressed and restless. Delirium - or so the nurses thought. But because he was unable to speak due to the tracheostomy cuff being inflated, Alistair could not communicate. The cuff inflation was preventing upper airway airflow and voice, so it was difficult to lip read his mouthing attempts. This was frustrating on both sides and the staff couldn’t tell if he was delirious or if he was distressed about something else entirely.
For every day a patient spends in ICU, they will lose around 2% of their muscle mass. That means after one week, a patient could lose around 14%, leaving them struggling with everyday activities such as standing, walking, talking and swallowing. In Alistair’s case, he had been in ICU for many weeks, and even lifting his head off the pillow was a challenge. When patients become this weak, being able to communicate their needs becomes even more important.
“The care is more unsafe when the patient can’t tell you what’s wrong,” Sarah told us. The psychological impact of losing the ability to communicate can also be profound. “Many patients suffer from psychological trauma simply because they can’t tell people what’s wrong with them, ask questions or speak to family.”
Sarah took the air out of Alistair’s trachy cuff and placed a one-way Valve to redirect the airflow through the vocal cords. At this point, everything changed for Alistair.
He calmed down completely, visibly relaxed, his respiration rate came down, he was no longer visibly anxious, and it became clear from our first conversation that he wasn’t delirious at all.
When Sarah asked, "Are you okay, Alistair?", he was finally able to explain that he was too hot, that his foot was hurting and that he wanted to know when his wife would next be visiting. When she asked where he was from, he told her in his Scottish accent about growing up in Aberdeen before moving to Manchester several years earlier.
As the conversation continued, Alistair's personality began to emerge. He was no longer simply a patient - he was a husband, a Scotsman living far from home, and a man with his own stories to tell. Not only could he now communicate his care needs, but he could reconnect with his identity. Sarah described this process in the following way:
When people are able to speak about themselves as a human, that’s when they start to get their sparkle back.
Shortly after this, Alistair’s family came to visit, and he was able to say, “I love you,” to his wife. “Everyone was in tears,” Sarah told us. “His wife hadn’t been able to hear those words in weeks, and suddenly, with the restoration of voice, that bond was restored, which was really uplifting.”
As Alistair became more able to use his voice, he could engage more fully in his own care and rehabilitation. He was weaned from the ventilator more quickly than had previously seemed possible because he could cooperate and express his fears, allowing him to leave ICU sooner.
Alistair's story is a reminder that communication is not a luxury in intensive care; it is a fundamental part of good care. Being able to tell someone you are in pain, ask a question, share a memory or say "I love you" can profoundly affect recovery, wellbeing and dignity.
Sarah and her colleagues have spent years championing the importance of communication and swallowing in ICU, arguing that they should be prioritised from the earliest stages of care. The care delivered by the whole MDT is more successful and humanised when patients can communicate effectively.
And perhaps that is what Sarah's story reminds us most clearly: behind every monitor, ventilator and tracheostomy is an individual who still has a story to tell. Sometimes, helping them tell it can change everything.
