Speech and communication are complex functions that involve listening, understanding, formulating a response, selecting the right words, and engaging the vocal cords to produce the appropriate combination of sounds. At this early stage, the medical staff couldn’t predict the severity of Matt’s impairment. How does one even begin to grasp such a vague prognosis—from minimal to substantial—and confront it head-on?

Three long months had felt like an eternity of silence, waiting for a fragile sound to escape his lips. Then came a raspy "yes," or a hesitant request to "go to bed." Each word was a hard-won crusade, a tiny spark of the man we knew flickering back to life. This was more than just communication; it was a lifeline thrown across the vast chasm that had separated us. Tears would well up in my eyes in gratitude that he could express even the simplest need. Finally, we could ask, honestly ask, what he wanted, and his nod or mumbled affirmation was a joyous confirmation. Our version of Twenty Questions became a delicate bridge back to connection, a painstaking but beautiful dance of rediscovery.

After Matt came home to live with us in September, he enjoyed interacting and talking (I use that word loosely) with people who visited. In the beginning, he was so quiet that we could barely understand 25-30% of his words. Everyone was obliged to lean in close, trying to make sense of his jumbled words and low volume by listening intently and reading his lips. Matt's ability to express himself depended greatly on the visitor's skill to engage him. My boss and friend, Peggy, was a natural. She was skilled at asking open-ended questions, which encouraged Matt to elaborate more than if asked a yes-or-no question—a strategy we should learn to use more often. It required patience to wait for him to find the right words and taxed our ability to understand what he was trying to say, just as it did when he was a toddler first learning to talk.

When we started outpatient speech therapy, we had no idea it was the beginning of a three-year relationship with his therapist, Jessica. “When Matt’s incident first occurred, the entire department was devastated on Sarah’s (Matt’s mother) behalf. We held so much hope for improvement, but there was a period when we were all bracing for the worst. But then our regular updates from our director shifted towards hope, although to what degree we could have never imagined.” Jessica kept up with Matt’s slow progress. She assumed that once he moved home, Matt would automatically transition to outpatient therapy at Sunnyview Hospital due to their expertise in neurogenic issues. She later confided to me, “When I heard he’d be coming to us at Saratoga Hospital…and to me, specifically, I was nervous. I remember disclosing my concerns to Eric, his soon-to-be physical therapist, and a department coordinator. I proclaimed, “I just want to make sure I do a good job with him.” Eric’s response was, “You have nothing to worry about. You’re going to be great.”

From the onset, the blinders were off. Matt’s impairments were profound. Looking back on Matt's initial evaluation, Jessica shared her early impressions. "When Matt first came with his father for his initial evaluation, I was simultaneously struck by the miracle of the whole situation: that Matt was sitting in front of me, alive, offering any response he could muster was nothing short of miraculous. At the same time, his initial scores on both expressive and receptive measures were severely impaired. He was unable to read or write. His voice was markedly hypophonic, often hoarse (a condition called dysphonia), barely above a whisper.

Prolonged tracheostomy use and inadequate focal cord closure were underlying contributors. I could still see the remnants of his tracheostomy site. A constant risk of aspiration—food or liquid 'going down the wrong pipe'—persisted whenever he tried to eat or speak. I also observed signs of apraxia of speech, where his brain struggled to tell his mouth how to form words; getting out, even a simple response, was tough. Truthfully, it was nearly impossible to adequately assess Matt fully when he barely spoke at all, and his cognitive function further complicated my sessions and his participation.”

Jessica admitted, “The number of different things we had to deal with from a speech and swallowing standpoint was daunting to say the least, and in just short, 30-minute sessions, twice a week. It was a heavy responsibility. I knew from my professional interactions, and from having followed along Matt’s recovery trajectory thus far, that Sarah and Mike had high expectations of what we did in therapy, what Matt would do on his own, and lofty goals for his outcomes, and I wasn’t sure Matt and I would be able to meet their expectations."

He was just starting to eat and drink again, but was still on a modified dysphagia diet of thickened liquids. It was imperative to address his swallowing function first and foremost as the safety priority. For example, Matt loudly performed vocal scales (Do, Ra, Me, Fa, So, La, Ti, Do) while simultaneously doing isometric arm exercises. Activating his arm muscles by either pulling up or pushing down on his chair added strength to his vocal cord closure—a mastery essential for safe speaking and eating. Once it was deemed safe to swallow without choking or aspirating, the focus of therapy could shift to speech and language function.

Concluding her reflections on Matt's progress, Jessica revealed a profound challenge from their early sessions: “Initially, Matt was one of the easiest clients I have ever worked with! Although his impairments presented a challenge, he rarely missed a session and always did anything I asked of him. I could see the former valedictorian in there: he showed up, he worked hard, and he always got it done. Yet, his interactions felt forced, if not robotic, and his essence so flat that it would barely budge the needle on a gauge. Imagine waving a hand in front of someone’s face and getting no response; that was Matt. “I could not see Matt’s personality.” This fundamental absence of his unique self was the missing link that spurred many of us to strive harder, to find ways to draw Matt out.

© 2025, Sarah Watkins