Physiotherapy Trauma Talks
In Physiotherapy Trauma Talks we discuss the key roles that physiotherapists and other healthcare practitioners play in the management and rehabilitation of patients with traumatic injury. Experts in trauma care offer their insights about in-hospital patient care and post-discharge follow up service delivery. New research in the field of trauma care and rehabilitation is shared to provide answers to your questions.
Physiotherapy Trauma Talks
When Respiration Meets Communication: Critical Insights for Trauma Teams with Dr Kim Coutts
Dr. Kim Coutts pulls back the curtain on the often-overlooked role of speech therapy in trauma care, revealing how this vital discipline can transform patient outcomes in the ICU. She explains that speech therapists are essential team members who contribute to managing post-extubation dysphagia, supporting patients with tracheostomy, and addressing communication barriers in the ICU. With a decade of clinical experience and her current position as a senior lecturer at the University of the Witwatersrand, Kim brings both clinical expertise and academic insight to this eye-opening conversation. Ready to enhance your trauma care practice through better collaboration? Share your experiences working with speech therapists with me using the link provided here.
Podcast website: https://physiotherapytraumatalks.buzzsprout.com
‘Cardiopulmonary Physiotherapy in Trauma: An Evidence-based Approach’ published by World Scientific: https://doi.org/10.1142/13509
Hi there, fellow physiotherapists. I am Helene van Asvegen, your host for Physiotherapy Trauma Talks, where we discuss everything related to trauma care. So if you are passionate to learn more about physiotherapy in the field of trauma to ensure that you provide the best possible care for your patients, then this is the right podcast series for you. So today I am joined by Dr Kim Kutz, who is a speech and language therapist and senior lecturer in the Department of Speech Pathology and Audiology at the University of the Witwatersrand. Kim, thank you for joining me.
Speaker 2:Thank you so much for having me. It's really nice to be able to be here and kind of shed a light onto the role that speech therapists can play in the ICU.
Speaker 1:Wonderful Kim. As we start, would you mind just telling our listeners a little bit about yourself and how you came to work in the ICU seating?
Speaker 2:Sure. So I did my community service at Helen Joseph Hospital in Joburg and I stayed on there for 10 years while I was doing my master's and my PhD. And during my time at Helen Joseph I would get the odd referral to ICU. And when I was seeing these patients I was realizing that actually I was getting them quite late and they were only referring certain types of patients to me.
Speaker 2:And after doing a little bit more extensive training with the nurses and the physicians and other allies about the kinds of patients I should be seeing in ICU, I then joined the ward rounds and started to advocate for patients about early intervention, early assessment, early identification, and I definitely became more of a permanent feature in ICU and started seeing almost all the patients there and I would screen everybody that was extubated. So then when I moved to WITS full-time, everybody that was extubated. So then when I moved to WITS full-time, I've then taken on the course of tracheostomy, icu, acute care, swallowing disorders, also head injuries. So it's something that I'm very passionate about and really want to create a lot of awareness for, especially in the South African context where speech therapy is not really a thought of profession in ICU.
Speaker 1:Yes, no, I think that is definitely very important, and you're right, not many members that work in the ICU are always aware of what the speech therapist role is, so it's great to learn that you were advocating for your role in that setting when you were still working clinically. Based on your experience and thinking particularly about the trauma intensive care unit, what would you say is the role of the speech therapist in that setting, with referral to the type of patients that you would maybe focus on more, versus others that might not need your input? If you could maybe just elaborate on that.
Speaker 2:Sure, there's actually so much that we do so. Patients who are intubated if they are intubated for longer than 48 to 72 hours, they can get something called post-extubation dysphagia. So anyone that's intubated for longer than three days should be screened automatically for a dysphagia. So regardless of diagnosis, regardless of diagnosis. So the stats vary. They, you know international literature says post-extubation dysphagia can be present in something like from 24% all the way up to 78% of patients in an ICU. So I think it's just better to screen all these patients post-extubation anyway, because it's also transient in nature. So you want to be able to identify these patients, because the last thing you need is for them to aspirate for two days and then they present with a pneumonia which just is going to complicate their recovery. Rather, manage their dysphagia in that transient stage, in that initial phase, to prevent these complications, especially in a resource-scarce setting like South Africa, whether we're talking private or public, you don't need patients longer in ICU than they have to be. So the whole goal for me about early assessments and early identification is to prevent complications so we can get these patients out of ICU. And it's quite an easy process to just screen a patient for dysphagia. So I would say everybody should be screened.
Speaker 2:So those are the patients who are extubated. But then obviously we've got the patients who are ventilated and have a tracheostomy in situ. Then we need to work with physios and dieticians on getting these patients weaned off the ventilator, getting speaking valves placed for them so they have some way of functionally communicating while they're on the ventilator and a tracheostomy, and then, once they're off the ventilator, we can then look at decannulating the patient. And these are decisions that get made with physios, ents, physicians. But it's a role that speech therapists can definitely play as part of the team is weaning this patient off their tracheostomy and making decisions around decannulation. And then, depending on the trauma itself, if there is a some kind of head injury, then it comes into the cognitive communication aspects of it, their ability to communicate functionally, their ability to understand, get messages across, pragmatic skills, all that sort of thing which is really important in ICU as well. So there's a lot that we can do and should be doing in ICU.
Speaker 2:Yes, and I suppose, with regards to communication tools for patients who are intubated, is that something that you can assist with absolutely so, depending if they are um, if they've got a tracheostomy in place, if they're connected to the ventilator, they are speaking valves that can get placed in the et tube itself so that patients can then communicate um in the tracheostomy I mean, and then otherwise there are communication devices that we can give them if that is not necessarily an option, but our goal is to always look at how we can try and get this patient to functionally communicate with what they have available to them.
Speaker 1:Yeah, okay. And when you approach a physiotherapist in the unit to explain to them what your role is, what do you tell them are your expectations from them to ensure that your approach together towards patient care is optimal?
Speaker 2:For me, respiration is the heart of everything that we do. If a patient is not able to control their breathing, doesn't have good control over their respiration, chances of them aspirating and having some kind of dysphagia is significantly higher. Also, they're not going to be able to breathe as well. It has implications for decannulation if there's an issue with their airway. So I would really like to work with a physio in terms of managing their respiratory system, working with them in terms of expectations of working on inhalation, exhalation, airway protection, getting a good cough. For us, having a good cough is really important in terms of sensation, being able to clear their airway, vocal cord closure. So a lot of the time, speech and physio would need to work on the same thing. We would just have different outcomes. So when I was in ICU, I rarely would treat a patient without a physio.
Speaker 1:Yeah, I know that's wonderful to hear about your real emphasis on teamwork in managing patients, especially those with tracheostomies. Do you find that other members of the trauma team that work in ICU are appreciative of your role? Have you had challenges from nurses or doctors?
Speaker 2:If you can maybe just elaborate on that a little bit and how you think that can be improved, so I'm talking from a frame of somebody who's only worked in the public healthcare sector before that because I acknowledge that public and private do have very different challenges and also coming from an academic doing the research who's very passionate about interdisciplinary work, especially in an ICU setting. So, yeah, my answers are going to be framed by that context and so, yeah, my answers are going to be framed by that context. So I think the Alliance were absolutely the best people to understand each other and work together and work well. We actually started a little Allied ward round on a Monday Fantastic and I learned so much from my other Allies Like it was speech, physio, ot, dieticians and social work that got together and we discussed our rehab plan and the decision making behind, why we needed to do certain things, and that for me, was such a valuable conversation to have to know why the dietitian was pushing a particular diet and then how I needed to adjust my therapy plan to accommodate the nutritional requirements of the dietitian. And then the physio understood what I needed to adjust my therapy plan to accommodate the nutritional requirements of the dietician. And then the physio understood what I needed in terms of respiration, in terms of dysphagia management, so they knew what to focus on in their therapy. Yeah, it was so valuable.
Speaker 2:Some doctors were more open to it than others and some doctors just very much want to get in, treat the patient by the protocol that they learned when they were interns and registrars and they haven't really changed and understood the value that perhaps an interdisciplinary approach to management and ICU can bring.
Speaker 2:And they know that they have to refer this patient to physio or speech therapy because it's a checkbox exercise, but not actually wanting to engage with us as to why it is important for this patient to see a physio or a speech therapist and what my goal is in ICU so understanding the medication that they're prescribing or the procedures that they're booking this patient in for, the implications that that could have on my rehab, or how I could then potentially reduce the need for certain tests or medications or therapies to be done. I think I would just like doctors to be a little bit more curious as to what we do and the value that we can bring, as opposed to just knowing that they have to refer to us and yes, it's a checkbox exercise but not really wanting to understand why.
Speaker 1:Yeah, no, I agree with you completely and I think in the sense, physiotherapists also feel that way when we work in the ICU, where some just do that tick box exercise and others are quite happy to fully engage with you regarding your role in patient key, and I love your referral to the allied health workers ward round in the ICU. I think that can add so much benefit to teamwork. So, just thinking about after discharge from hospital, you've described within the ICU, the role of the speech and language therapist in managing patients who are still intubated and need to be weaned and also doing a swallow assessment on patients who come off the ventilator and are extubated. But thinking about post-hospital care, what is the role of the speech and language therapist in that context?
Speaker 2:It's for me, that's where we start to work very much more closely with the family, and another aspect that I work quite closely in is third party disability, so understanding that, even though you are not disabled, you are caring for somebody that has some kind of disability and the burden that that can have on you. So for me, when a patient goes home, it's really important to work closely with the carers and whoever they are living with and training them and getting their buy-in and making sure they are supported in the process, because if the care is not supported, your rehab plan for the patient is going to fall flat and the home environments. Setting that up early prior to discharge is incredibly important. Managing expectations, what they're going to need to do, getting by and before they go home is really important. And then also looking back at then community reintegration what do they need to get back into work? What do they need to get back to social activities that they were doing? Do they have a significant communication impairment? That needs to change. Maybe it's something really subtle that it's just like pragmatic or basic cognitive issues and that attention span is really poor or that they're not able to maintain a conversation with people anymore. What do I need to work on to improve their quality of life, that they can be functional when they go back home.
Speaker 2:And also eating then is a big thing because you know, can they go out if they're on a modified diet, maybe they're on a peg. You know going into a restaurant is going to be difficult. What do you do at big family functions, holidays? And also, you know, depending on the context that the patient is from and also, you know, depending on the context that the patient is from, modifying a diet can also be quite expensive in the days where there's not always electricity, there's not always water, if you're having to puree foods or you're having to get thickness or something. These are conversations you need to have with carers, loved ones, patients about what's actually feasible and manageable at home. So there's a lot of stuff you have to do before discharge. That sets you up for when they do go home. Yes, definitely.
Speaker 1:Kim, as we finish our discussion, are there any last thoughts that you would like to share with our physiotherapy audience?
Speaker 2:I think, talk to your speech therapist, especially in the private sector. I know it gets a little bit complicated and you usually just communicate through notes on the system, but I think just picking up the phone and having a conversation about this is how this patient was today. This is what I'm doing. These are my goals. Can I help you with something? Can you help me with something? I, I think just joint planning, understanding how we can manage things together and being open to learning from each other, I think is very valuable. Let's work together in the most feasible way possible that our context will allow.
Speaker 1:Kim, thank you so much. Those are definitely words of wisdom that you shared and I completely agree with him. Thank you for your time. Thank you so much. It are definitely words of wisdom that you shared and I completely agree with him. Thank you for your time, thank you so much.
Speaker 2:It's been a pleasure.
