STARES #2: Communication

SITUATION:

My patient, Mr M, was 58 year old male who suffered a left sided MCA infarct three months ago. He has been undergoing intensive rehabilitation at Shenton Park Hospital since then with great success. At present his main impairments are in speech, as he has severe expressive dysphasia and mild receptive dysphasia, reduced joint range of motion into shoulder flexion, extension and abduction (with pain at end of range) and decreased muscle length of pectoralis major and latissimus dorsi on his right side. He is currently independent in all functional mobility tasks, using a step-stand transfer to transfer from chair to bed and ambulating independently without an aid over 15m but for longer distances requires a walking stick.

Before seeing this patient I was given a brief handover regarding his limited ability to communicate effectively. Mr M has extreme difficulty communicating verbally as he can only say ‘no’, and does so repetitively, with minimal ability to vary his tone of voice. His main method of communication is via hand gestures, predominantly a ‘thumbs up’, and facial expressions, always greeting people with a smile and ‘thumbs up’ combination.

TASK:
My task in this situation was to treat Mr M’s lack of range at his shoulder with mobilisation and muscle lengthening techniques. More important than this though was that I also had to establish an effective method of communication with this dysphasic patient as it was known he had pain in his shoulder and so I needed to closely monitor this throughout my treatment.

ACTIONS:
After introducing myself, my initial thought was that I needed to confirm what signals/gesture he used to say ‘yes’ and ‘no’. For Mr M, he was able to say ‘no’ and used a ‘thumbs up’ sign as ‘yes’.

After instructing the patient with verbal cues to move into supine lying, I assessed his shoulder joint range and muscle length as a baseline assessment, also noting any pain.

Mr M did get pain in his shoulder which I monitored by continually through by asking about pain to gain a yes or no response, I closely observed his facial expressions too looking for any wincing or watery eyes. Although it was difficult communicating with this patient I wanted to try and gain rapport with him and speak to him as I would other patients. To do this I used clear and concise closed questions and pointed to objects I was referring too. This was effective until he wanted to answer with more than yes/no and tried to explain things to me. I did not know what to do in this situation and it was very unclear to me what the message was he was trying to get across despite many unsuccessful guesses. At this point I had to discard what he was saying and continue with my treatment.

Mr M obviously had something that we wanted to say to me as he kept pointing to things and saying ‘no’, ‘no’, ‘no’, which got confusing as he was not using the word no in the appropriate context, making me question his use of the word previously in the session. In an attempt to understand Mr M, I brought out paper and a thick marker for him to write down what he was talking about. I thought this method was going to work well until I realised his handwriting was basically illegible and he was only able to write very simple words. Unfortunately, after multiple attempts and asking my supervisor if she could understand what he was trying to say, we were again unable to work out what he wanted. At this point I re-assessed his shoulder and concluded my treatment with him as my supervisor required my assistance with another patient.

RESULTS
Despite a successful treatment on his shoulder with the re-assessment indicating an improved range of motion my ability to communicate well with this patient was questionable. The result of my inability to find appropriate methods of communication with this patient meant that I was unable to have longer, more meaningful conversations with the patient which led to me not able to develop as good a rapport with this patient as I’ve been fortunate enough to gain with other patients. At times, Mr M also became slightly frustrated at his inability to explain himself and gave up trying to communicate with more than the signalled yes/no response.

EVALUATION
This was the first time I had been exposed to this speech impairment in the clinical setting and had not been given an opportunity to prepare for this prior to seeing the patient and I definitely believe that my communication skills were sub-optimal in this setting. In regards to my communication with this patient I felt quite disappointed in myself following this session as I thought I knew more strategies and tools I could implement to communicate with dysphasic patients. The disappointment was predominantly due to the fact that Mr M obviously had something he really wanted to be able to tell me, based on his multiple attempts, but I could not decipher what that was. On a more positive note, I do believe that I effectively established signals for yes and no which allowed me to monitor his level of pain throughout the treatment and stop when the pain got too much.


STRATEGIES
I explored a number of avenues to get more ideas on methods of effective communication with dysphasic patients. Initially I asked my supervisor (who has been treating Mr M since his admission) what methods she has found to be most effective with this patient. She suggested using pen and paper for him to try and write words, which I had tried with him, and also instead of him writing, you write words or draw images that he can recognise and say yes/no as to whether that’s what he is trying to say, for example drawing family members. I also asked my supervisor if there were any resources/handouts that she was aware of that I could read for other possible strategies I could try with this patient and for future patients.
Additionally I reviewed our university course materials on methods of communication with speech and/or cognitive impairments which I found to be very beneficial in directing me to further readings specific to dysphasic patients.