Despite an ongoing shift in medical training across the country to enhance physician communication skills, there remains limited formal training communicating with patients who have tracheostomies. With over 100,000 tracheostomies performed every year in the United States, clinicians in every field will encounter patients who have individualized communication needs. These patients often experience isolation, depression, and anxiety due to an inability to interact and communicate with others. Clinicians can and should prepare patients and families by addressing these concerns early in the medical process. In only two years of training, I have taken care of many patients with tracheostomies and felt ill-prepared to handle both medical and social needs associated with them.
Three patients, three lessons
Patient A was an older gentleman who needed a tracheostomy after a prolonged intubation. He became more withdrawn after his tracheostomy despite medical improvements in his overall condition. A prior stroke made it difficult to use communication boards and write out his thoughts which led to isolation and depression.
Patient B was a middle-aged man who needed a tracheostomy for similar reasons, but his family was more involved and brought an iPad with several applications they found for communicating. They found their own resources and tools to help him.
Finally, Patient C had a chronic tracheostomy without a speaking valve. He would only shake his head yes or no and it was frustrating because we could not get many details from him. Ultimately, I found out he could not write because he had literacy difficulties and had been too embarrassed to share.
Individualized planning is key
Each of these scenarios shows that individualized planning and interventions must be used when taking care of patients with communication barriers. Clinicians should do a better job of assessing patient literacy and physical abilities prior to the procedure so postoperative communication can be optimized. Writing and pointing may be limited by a stroke, amputation, or other physical impairment.
Many applications and websites exist to help with communication, however not all patients have access to electronics or the internet. For patients with vision impairment, creative strategies may need to be employed for them to see boards or paper. If I would have done a better job exploring communication needs these patients may have had better communication strategies.
A multidisciplinary solution
Managing patients with tracheostomies is a team effort from ENT physicians, speech-language pathologists, social work, respiratory therapists, and the medicine team. Each person represents a chance to address patient emotions, help improve communication strategies, and screen for depression or other mood disturbances. Medical training should be enhanced to include multidisciplinary training because all specialties will take care of patients who have acute or chronic tracheostomies.
The Internal Medicine Department at the University of Kentucky has created a conference series partnered with the ENT and palliative care departments to create a didactic curriculum to improve medicine residents’ care for these patients. More programs should consider this type of collaboration because our patients deserve high quality care and ensuring communication needs are met is a group effort.
Alyssa Lambrecht is an internal medicine resident.
