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...

Being Threatened

How many of you have a job where you could, at times, be physically or verbally abused? And threatened? And pushed beyond your limits of self-dignity?

Welcome to the ER.

Anyone who has ever worked in an emergency department or a trauma center has a story to tell about being threatened. It's not a good feeling and, in fact, is something that one can carry with them long after the event, dwelling on their minds and weighing down their hearts. We all, I think, have a little part of our self-worth damaged at times like that. And even though you did nothing wrong, you still ask yourself repeatedly "What did I do to deserve this?" or "Could I have done something different?" Nine times out of ten, that answer would be "no." But that crazy thing called guilt can flip the coin and make you feel like you were responsible.

For example, when an alcoholic or druggie comes in and threatens to "beat the shit out of you" or "find out where you live and come carve you up," it's par-for-the-course, something we have all been trained to deal with. We are asked to look beyond the abuse and realize that it's "not the patient talking" but, rather, the drugs and alcohol. Yeah, okay. For the most part, I can buy that. But we all have limits, and it takes tremendous professionalism and restraint to continue treating that patient. And of course, we always do.

Likewise, if a psychiatric patient presents during a crisis, a break from reality, they may lose the ability to discern between what is normal, accepted behavior and what is harmful, threatening behavior. And again, the ER staff is usually on the receiving end of their irrational actions or words. Recently, a schizophrenic patient sprayed us with her saliva while glaring at us with her distant, disconnected eyes, spatting away and trying to bite or hit anyone near her. Even after a face-mask was placed, she still managed to hurl some extremely hurtful, vulgar comments at our staff, particularly at a medical student who had some acne issues and a female guard who was not a size 8. One of our nurses ended up with a bruise.

Hell, about ten years ago, I even had a psychiatric patient tell me that he was going to find out where I lived and "take you out." I hadn't been the first doctor and I'm sure I wasn't the last that he threatened but, trust me, you don't sleep well after something like that.

We accept these words and these blows, these mean-spirited, personal insults delivered with flailing arms and legs, because we signed-up for our jobs in the ER. But, we are still human, and there are days when this type of threatening or abusive patient is harder to accept and deal with.

The hardest part, though, isn't the expected threats, such as from the above patients. Rather, it's the unexpected threats from the sane-appearing patient who decides to take out all of his frustrations on the ER staff. For this reason, I rarely let a patient get between me and the treatment-room doorway.

A while back, I signed on to treat a twentyish male who had waited for about two hours for a complaint of one week of cough and cold symptoms, exacerbating his asthma. He continued to smoke despite feeling that his symptoms were getting worse, per the nursing triage note.

As I walked down our brightly-lit corridor, towards his room, I exhaled a deep, thankful breath, happy to have my last patient survive her stroke. Unknowingly, though, I was walking towards a room of rage.

I pushed the curtain to the side and walked into the room, all while extending my hand to introduce myself. Lying on a cot in the dimly-lit treatment room, watching the small TV in the upper corner, was a young man who looked very pissed-off. He may have weighed 130 lbs. wet, 5'7" or so. After I entered, he shifted his glaring eyes onto me.

"Hello," I started, "I'm Doc..." Unfortunately, I didn't get to finish. In a flash, this patient had jumped off his cot and towards me, his arm cocked-back and his fist balled. He stopped a few feet in front of me.

"I had to wait almost three f...ing hours for you to get your ass in here. Can't you see I can't breathe?" He yelled in full sentences, no distress evident. By triage notes, he was stable and had had an excellent oxygen reading. There was no mention of this patient being unreasonable, although I later learned that security had to approach him in the waiting room to calm down. He continued. "You motherf...ers are treating everybody but me."

Yes, my heart was racing. And yes, I was completely caught off-guard. We had a brief moment of silence where our eyes locked, and I could see his extreme rage.

"Put your fist down," I said firmly, holding my ground, shifting my eyes to his cocked-arm. "If you touch me, I promise you that you'll be covered with cops and security before you can blink." Instinctively, while speaking, I raised both of my hands, preparing to catch or block a thrown-fist. Why didn't I retreat? I'm not sure, exactly. Although I had about 70 pounds and six inches on this patient, that would mean nothing if this guy had a gun or knife. But frankly, during a moment like this, it's hard to fully grasp all that is happening.

The patient continued to keep his arm cocked as he ranted. "Motherf...ckers, sons-of bitches, assholes," he yelled, "making me God-damn wait like this. I want some God-damn treatment and I want it now." Finally, after his rant, he took a step back towards his cot.

By now, because of the commotion, I knew that security would be rushing to the room. And they did, but not before one of our techs, a 350 lb. brute, came in first to back me up. Security soon followed and, after we offered some very brash options of either being arrested (if he continued his behavior) or cooperating or leaving on his own accord, the patient requested to be treated. Since I'm not easily intimidated and wasn't sure how ill he was, I agreed to treat him, but not until after I spelled out in exact terms how we expected him to behave. He hesitantly agreed to our terms.

Under watchful eyes, I obtained a history from this patient and performed a thorough exam. I tried my best to maintain my professionalism and act as if this patient hadn't wanted to jump me mere minutes before. Fortunately, I found him to be just as the triage nurse had noted. He had been appropriately placed behind our more critical patients for treatment.

The respiratory therapist came down, soon after, to give this patient a breathing treatment. Before she entered the room, I explained to her why security would be sitting outside of his room in the hallway. We both walked to the room together, only to find no security sitting outside.

"Go back to the station," I said, "I'm not sure what happened."

Well, as it turns out, this patient, following another angry outburst aimed at our security, had decided to leave without any further treatment. And wouldn't you know, the next day he returned. I wasn't even aware he was back until I heard a big ruckus. Again, a lot of verbal abuse towards one of the ER nurses and one of my partners. Our security was ready, though, and the police were notified.

Although we'll never know for certain, there did not appear to be any alcohol or drugs involved. No psychiatric history, either. He simply was a very disgruntled, angry man who wanted his medical treatment immediately, for symptoms that had been present for almost a week. In order to jump the line of waiting cardiac, stroke, and trauma patients, he had been willing to risk threatening several of us.

At times, we can face some real dangers with our ER jobs. My hat is off to all of my fellow ER comrades, from the secretaries to the techs, from the nurses to the docs, and from the security to the police. I salute your continued resilience and professionalism, especially during these abusive moments.

As always, big thanks for reading. The next post will be Friday, March 12. Until then...