Friday, May 14, 2010

Speaking For Mom

I walked into Room 28 to examine a woman who had presented to our emergency department with complaints of abdominal pain. She had initially been examined by our chief resident, who was under my supervision for this particular shift.

Unfortunately, this patient was a "frequent-flier," presenting to our ER multiple times in the past few years. Complicating the matter, she spoke no English. Despite our offers to provide a translator during her visits, she refused. Every time. Instead, she placed that responsibility on her ten year-old daughter's shoulders.

My resident was somewhat flustered by this patient. For one, her multiple visits to our ER were always for chronic issues that, despite significant past work-ups, never amounted to any significant findings. Secondly, the language barrier. When a patient and a physician do not share a common language, there is always a concern that some important fact or angle may be overlooked. In addition, this patient had now been in our country for a few years. During that time, wouldn't you expect her English skills to advance a little bit? I can't picture myself living in France for two years and not learning some French. Yes, no, wine. Those words would roll off my tongue in the first week. This patient, for whatever reasons, seemed to have not made much effort in learning even basic English words.

Which leads us to my resident's biggest frustration. The daughter. And the burden placed on her to translate for her mother. If the patient had come to our ER over thirty times in the past few years, how many times do you think the daughter had been with her? Even conservatively, if the daughter had accompanied her mother on half of those visits, it's still too much. In addition, most of her mother's visits were regarding abdominal pain. Some of the questions asked during history-taking can be very sensitive and specific with this complaint and, yet, the mother wouldn't answer a question unless it was through her daughter.

I walked into the room to find a laughing patient sitting upright in her cot, watching TV. Despite her loose hospital gown, I could appreciate this woman's large size. She appeared very comfortable, though, and in no acute distress. Her daughter sat in a corner chair, also smiling as she looked upward at the TV. She was beautiful. Dark hair, dark eyes, long lashes, and dangling pink gemstone earrings that swayed with her laughter. She wore a pink Hannah Montana sweatshirt. Looking up at the TV, I was not surprised to see the channel was set to The Hannah Montana Show on the Disney channel.

"Hello," I said, holding out my hand to the patient and shaking hers, "I'm Dr. Jim, and I'll be treating you today with Dr. Mary, whom you just met. How are you?"

The patient looked from me to her daughter, who translated everything I had just said. When her daughter was done, the patient turned back to me and silently nodded. I continued focusing on the daughter, holding out my hand and walking around to the other side of the cot where she sat. "You are her daughter?" I asked. She nodded. "What is your name, honey?" "Annabelle," she answered, shyly.

"Annabelle," I said, "we appreciate you being here today to help us with your mother's care. Would your mother want us to call a translator instead, though?" Annabelle translated my words for her mother and returned her mother's response to me. "Absolutely not," Annabelle said.

"Okay, then, Annabelle," I said, "I will ask you all my questions and you can, in turn, ask your mother, okay? If there are any questions you don't feel comfortable with, just tell me and I will call in a translator."

Even this, Annabelle translated for her mother, who's return response, through Annabelle, was "There is no question that my daughter has not already heard."

So, I asked away. Fever? Nausea? Vomiting? Diarrhea? Where is the belly pain? Similar to past episodes? Chest pain? Trauma? I kept it short and sweet. Finally, I briefly asked about any urinary problems or vaginal problems. Annabelle didn't even flinch, asking her mother my questions and relaying her mother's answers. She was a translating pro, albeit at the age of ten. Practice makes perfect, I guess.

After the questions, I performed a physical exam that was stable and unremarkable for any abnormalities. I reviewed a new set of vital signs, also normal. This was all similar to what my chief had found. This patient's blood and urine work had returned prior to my exam, even, and I was armed with the knowledge that all of those results were normal as well.

I explained the results of my exam and the testing to Annabelle, who in turned spoke to her mother about it. The mother seemed genuinely happy. I explained that I was going to call her family doctor and review the results of our exam and testing and would expect her to follow-up for her chronic abdominal complaints in the morning with him. She agreed.

Before leaving, I focused on Annabelle. "You were so helpful today. Did anybody give you any stickers yet? Or a popsicle?" Annabelle didn't answer me but, instead, turned her face from me and toward her mother and started talking in their native language. It took me a minute to realize that she had thought those last questions were directed toward her mother.

"No, no, no, honey," I said, interrupting her and laughing. "Annabelle, I was asking you those questions. Did you get any stickers or a popsicle for being such a big help with your mother's care today?"

"No, Doctor Jim, I didn't," she replied, shyly gazing to the floor with her eyes. Her voice, in English, was quiet and faint; in her native language, fluent and guttural and husky.

"Well, Annabelle, your mother and we are sure lucky to have you translate for us. Thank you very much. Let me go get you some thank-you stickers, okay?" She nodded yes to my words, smiling now, her secondary teeth perfectly white and evenly lined. Her smile lit up the room.

I left the room, hearing Annabelle's explanations to her mother grow faint as I walked down the hallway. While my chief called the mother's doctor, I perused through our sticker collection and picked out about fifteen or so for Annabelle, including some new kitty-cat ones that I couldn't wait to get rid of (sorry, just not a cat fan here). I went to our employee lunch room, where we keep our popsicles, and grabbed Annabelle a bright blue Italian ice. Who doesn't like blue popsicles, right?

As I walked back into their treatment room, my chief resident was just leaving. "Everything all right?" I asked her. "Everything's good," she assured me, "Dr. Smith is going to see Mrs. Demshonova tomorrow at 9 a.m.

Perfect. I walked in and handed Annabelle her well-earned stickers. "Do you like cats, Annabelle? " She answered with a nod, hurriedly scanning through each of the stickers. "And here," I said, pulling the popsicle out from behind my back, "here is a blue popsicle for all your hard work." She looked at her mother who nodded to her, and Annabelle shyly took the popsicle from my hand. I finished. "It sure was nice meeting you, today. Thanks again for all of your help."

As I began retracing my steps out of the room, Annabelle's mother spoke up. "Excuse me, sir," she said, in broken English. I stepped back in and walked towards her cot, surprised to hear her speaking English. "Yes?" I asked. The patient looked from me to Annabelle, who was devouring the popsicle while rechecking the stickers, and back to me again. "Thank you," she said, grabbing my hand and squeezing it. "Thank you," she repeated again, more softly, for good measure.

"You're welcome," I said, returning her transcending smile with my own simple one.

I walked out of that room and realized that this was a good mother. And Annabelle, of course, a good child. Although I wouldn't expect my ten-year old to translate for me, this patient did. Whether is was cultural or not, I don't know. I do feel confident, though, that this mother wasn't being abusive of Annabelle, she just expected a family member to translate for her. A family member who just happened to be ten-year old Annabelle. Nor do I think the mother deliberately abused our ER with so many visits. Again, I simply think she didn't understand the process of following through with her chronic complaints with her family doctor. What do you think?

The patient and her daughter, after being discharged, walked down the hallway toward the exit door. Holding hands.

I walked back to my chief resident. "They turned out to be quite nice in there, didn't they?" I asked. "Yes, they were," the chief said, happy with the outcome.

Hopefully, she learned a little something besides clinical medicine from this case.

I know I did.

As always, big thanks for reading. I hope you all have a nice weekend. Next post will be Monday, May 17. See you then...

23 comments:

Empress Bee (of the High Sea) said...

do you think the mom is just scared an unknown translator will make a mistake and she has trust in her daughter? that's what i think. i hope her dr. discovers what the problem is though.

it is a beautiful story though and i enjoyed reading it.

smiles, bee
xoxoxoxoxoxo

Kate said...

I know you're in an ER, so you can't really plan ahead for translators, but we have a great relationship with our translating service. Sometimes, even though the family doesn't want one, we'll schedule for them to come anyway and let them chat in a room before we try to work with them. They either click with them or not and if they choose to use them, great! If not, the translator leaves and we make do the best we can.

It's one of those things - I guess. Making room for a relationship before we get clinical with them.

Just like you did with the daughter.

rlbates said...

Not sure what to say. Wish Annabelle had no need to be a translator at age 10.

Cal said...

I guess it must be a cultural thing, to keep the private stuff within the family, and not want a translator to know about their personal issues. Maybe the patient would think the translator is not bound by the same rules as doctors and will spill the beans within their community? (Presumably the translator could move within the same social circles as the patient, if they happen to be from a common descent).
Good storytelling!

Dr. Mongo Lloyd said...

Doc, I think you just used the patient's last name in this article.

Leslie said...

I think you are right "cultural thing" is likely. About the pain...do you think it could be somatic...possible history of abuse? (Yes, I have abuse on the brain right now, but it is a viable possibility.)

Wonderful story as always!

Heather said...

It's funny...I'm taking this course in Trans-cultural nursing and we hve been talking about some of these same things. I'm going to share this with my class.

You're a good guy. However, blue Popsicle is awful to get out of clothes! ;)

rheumablog said...

Wonderful story, Dr. Jim. Since this patient obviously wasn't there for narcotic meds, I think I'd go with the cultural explanation for her use of her daughter to translate. That could also explain why she doesn't speak even a little English, even after two years in country. Perhaps her community consists only of people who speak her language, and since her daughter can speak English, she has no real motivation to learn. It IS hard for an adult. I lived in Germany for six years, and while I did eventually learn enough German to get along, I was never fluent. I had an awful time learning the language. AND I was surrounded, almost always, by the American community and Germans who were fluent English speakers.
You were really sweet to make sure that little Annabelle was recognized for her help and rewarding with the kinds of things all kids love. Blue popsicles, indeed! :)
-Wren

Morris said...

CATS RULE!

dogs drool!!!

Hisssssssssssssss

Maha said...

You're an awesome doctor :) And I would STILL love cat stickers if I was offered some!

I find the same with many elderly people in my community - despite the fact that they have been living in Canada for a long time they haven't learned proper English because they always have us to translate.

Katie said...

That's incredibly interesting, actually! In class we always talk about how to not force a family member to interpret, especially in a medical setting, yet here was someone who wanted that. This one's going to leave me pensive for awhile.
And good job with the popcicles and stickers!
<>< Katie

Rositta said...

What an interesting story and what a wonderful little girl. I too had to be a translator for my parents at around 8 years of age but thankfully not in a medical setting. It took my parents a couple of years to learn reasonable English. Interestingly, as my mother aged she seemed to loose it and I again became a translator this time in a medical setting. There are no translators in hospitals in this country. I don't know if free English courses are offered for immigrants in America but here in Canada they are. Even so I know a number of people who have been her 30+ years who still don't have a decent command of the language. Some people just have difficulty with languages, look at me...I can't learn Greek to save my life, LOL...ciao

Rositta said...

As an aside, does gallbladder pain show up in blood work? I once went to ER with horrible pain and they never did diagnose it, I did that myself and I was right...ciao

Chrysalis Angel said...

This story reminds me of my girlfriend and her mom. They have been in the country a long time, yet the mother has never learned our language. My girlfriend still translates for her, and it's been way past 2 years. I don't know why she doesn't teach her, but that's how it is.

They don't want an "outsider" between themselves and the physician. They feel their information is only to be given to the doctor, as one of your other commenters stated.

I loved the way you were with the child. Perfect picks for her.

You are doing such a great job with the blog. I enjoy reading.

911RN said...

Our ER uses a telephone translator service that has probably 35 languages or more. It is great- have 2 mobile phones, one for medical practitioner and one for patient.Say what you want in English and translator spits it out to patient, in their native language, in a three way conversation. We can even use it to call patients at home for follow up on cultures etc.

I have had to use translator line for not only Spanish but Romanian, Chinese, Russian,French,Polish, Portugese etc. Our area receives many foreign travelers. We also have many foreign exchange students that work here on visa, in the summer. From Russia, Thailand, Korea etc. Their English is usually fair to good but it has been my experience that they don't understand as well, in the medical setting.

It is frowned upon if we use staff that are bilingual if they are not trained medical translators. However, for our Hispanic population, we, too, rely heavily on family members to translate -more often than not- their young children! I have had children as young as 6 be the spokesperson for the parents. Usually the moms. Sad, in some sense, but true.

Blue popsicles ROCK...is there a need to stock any other kind??!! Lost points, with me, Dr Jim, on the not liking cats thing:) Very relevant post that was enjoyable and caring so... I'll forgive this one noted character flaw.

Anonymous said...

I do not think it was abusive to have her daughter translate. It was; however, an abuse of the ER. Did you try to communicate to her that these ongoing abdominal complaints don't constitute an emergency and that she should go see a doctor in a clinic-perhaps she could find a doctor who speaks Spanish. What makes you think she's not capable of understanding that? She's probably smarter than you're giving her credit for being.

If she and people like her had to pay for these visits, the visits would stop, the patients would be no worse off and the time could be used to help people truly suffering from emergency situations. I don't understand why you'd feel satisfied after the encounter when she'll probably just keep coming back for reassurance with other folks footing the bill. (I just paid off a $1500.00 ER bill- I was having heart attack symptoms. It takes me a little over a month to earn that much at my job. It really isn't fair that people get away with abusing the ER like they do.)

Leslie said...

Anonymous, you know what is unfair?

#1 that you assume Dr. Jim didn't try to explain that to the patient (or that it is any of your business if he did). Are you familiar with the term "poetic license"? Dr. Jim's blog is for stories and entertainment not politics. If you want to talk politics about the ER/ED, there other blogs that take on this topic.

#2 that you assume the patient didn't have insurance. You don't know her situation.

#3 You leave a comment with snide remarks under "anonymous"...man up and use your name. It is easy to make all manner of rude comments when no one knows who you are.

Anonymous said...

Sorry, Leslie. I was visiting this site for the first time and misunderstood the flavor of the blog. The author did ask "What do you think?",though. Since most patients described on medical blogs are composites I don't find it inappropriate to make assumptions - it's not directed towards a particular person so it's simply expressing an opinion regarding a situation that does, in fact, exist. Obviously not every person who fits the composite stiffs the hospital but many do. I should know - algunos son miembros de mi propia familia. Espero que usted me pueda perdonar. As requested, I shall not return :)

Leslie said...

Gracias por explicar. Claro que le perdono.

You should come back, Dr. Jim is a great story teller.

Chrysalis Angel said...

I agree with Leslie. You should come back and read with us all. This is a great site, and you have found an exceptional author (not to mention a great group of visitors).

It's easy for there to be misunderstandings at times. The main thing is to be respectful of one another in those moments. It's usually in those instances that we learn from one another. This author is a good man, and I believe you would enjoy reading.

Rogue Medic said...

She may avoid speaking in English out of fear of making mistakes. I know a few words of several different languages. I avoid trying to figure out what people are saying, at least I avoid acting on what I think they might have said, since I find it so easy to be misunderstood in the one language I do speak fluently.

Maybe she wants her daughter to learn to be assertive and to deal with people, and maybe to be a doctor some day.

Anonymous said...

I wonder - repeated ER trips for a complaint such as 'abdominal pain' without having any significant findings - my sense was that this woman wants reassurance about "something". I wonder about doing a screen for domestic violence, depression, somaticization of intrapsychic distress - often with a 'frequent flier' these are part of the picture. Having the daughter as a translator may have multiple meanings/purposes, including a form of defense against being asked uncomfortable questions. I would wonder about the idea of having a translator 'stop by', or having an MD who speaks client's own language see her when she comes in, if that can be arranged. It's great that the daughter is doing such a good job, but.....I wonder what else is going on here.
PS signing as anonymous 123 as I do not have a URL or Google identify.

Heather said...

beautiful post. i'm not going to comment on the translation issue, but on the relationship. honestly, reading about that mother and daughter, i have tears. whatever the mother's reasons for having her daughter translate, clearly the daughter did what she did out of love for her mother, and the mother clearly loves her deeply, too. it's tough, though, when you have children while dealing with chronic health issues. my daughter, who is almost 8, knows more about hearts, thanks to her youngest brother, than a lot of residents i've met. i've often wondered if it's a good thing, but blithe can tell now when asher isn't well just by looking at his colour; she can see the difference between blue and grey, she notices when he's sweaty and/or puffy, she helps him to sit down and relax when he's SOB. there was one time, the kids were with their grandparents, and blithe told them that they needed to call me b/c asher didn't look right. "his colour's off and he's sweating too much" (it was winter). she has learned all this out of love for her brother, and even at 7, she can speak up and advocate for him. thank-you for the compassionate look at these kinds of relationships. <3