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...

Popsicles & Pudding

I walked by the nurses' station, casually glancing through the open doorway. Happy for what I saw, I immediately came to a halt and backed up a few steps.

Kids. Two of them. Innocent, smiling grade-schoolers. Sitting on blue vinyl-topped stools at the nurses' work counter. They were doodling in thin, grayish, hospital-issued coloring books, crayons spilled to the sides of their pages. In front of each child, a plastic pudding cup sat, a white spoon handle rising from the middle of each chocolate mess. Stickers covered the rest of their counter space, layered like replaced shingles randomly tossed from roof to ground. The kids looked happy, content.

I couldn't help but smile to myself. Another nurse had earned her wings.

As with any other profession, to be in the medical field, you must carry a certain spectrum of talents. A sufficient font of medical knowledge, of course, accompanied by a respectable work ethic. An inherent sense of the happenings in the workplace. Passion. And respect for your fellow mankind, regardless of whatever capacity you encounter them in.

Most important on my list, though? Compassion. Easily. And not just compassion, but compassion delivered with kindness. Imagine, two staff members are each giving a homeless person a turkey sandwich. One tosses the sandwich to him as he's walking out the door. End of story. The other hands the sandwich over, sharing some eye-contact and a smile, maybe even shaking hands or patting the homeless person's shoulder.

Same task accomplished. But which one delivered the compassion with kindness? Was the energy necessary to be kind in this circumstance monumental? Hardly. When I saw these kids sitting comfortably in the nurses' station, I was recognizing a nurse's compassion delivered with kindness.

As it turns out, these children were in our ER with their sick mother. Fever, vomiting, diarrhea, abdominal pain--all symptoms that made the mother nervous. A single-parent household, a single-income checking account. No local family. No available babysitters or friends. No time to be sick. No choice but to bring her two younger kids with her to the ER.

The kids were typical elementary school-age kids. Initially, when they arrived, the kids sat in the lone corner chair of the treatment room, squeezing themselves between the black, plastic armrests. While their mother changed into a hospital gown, had her vitals taken, and had an IV started, these little kids sat quietly, a little confused and a lot scared, I suppose, soaking in all the happenings. After their mother was made comfortable, the nurse ran and got each child an Italian ice and turned the television on to a suitable station for them.

Soon, as kids do, they started getting a little more comfortable and exuberant within their surroundings. The TV remote became their dodge ball. The volume was played with, the channels were flicked randomly, and some minor argument started over which child had more room in their shared chair. Finally, to help the mother get a little rest and receive her treatment in a quieter setting, the nurse removed the children, taking them to the nurses' station and setting them up with some distractions and pudding.

It worked. And that's when I happened to walk by, finding two calm, coloring kids snacking on pudding.

"Hi, guys," I said to them, looking over their shoulders at their colorings, "nice job. You both are really good at coloring."

They both looked up at me, not sure what to make of me since I wasn't their mother's doctor and they had never met me.

"Don't stop coloring on my account," I told them, "I just wanted to say that you both are doing a great job there."

They showed me their shy smiles before continuing on.

Jamie, the secretary at this station for the day, shared with me the kids' story. When she was done, I was smiling big. "Thanks for helping out with the kids, Jamie," I said, "I'm sure this wasn't in your job description."

"Not a problem" she said, herself the mother of a very nice, respectful middle-school son, "this is the fun part of my job."

Jamie told me which nurse was taking care of these kids' mother and, because I had a few free minutes, I sought her out. She was a recent graduate and had just started in our ER this past summer. Already, she had impressed me with her skills and knowledge and work-ethic. Now, I would add compassion to her list of strong credentials.

"Lindsey," I said, standing in the hallway, "do you have a minute?" "Sure," she answered, looking a little nervous, "what's up?" "It's nothing bad, Lindsey," I assured her, "I just wanted to tell you how impressed I am with the way you extended yourself to those children of the sick mother. I'm sure she really appreciates your kindness to her kids."

Lindsey blushed, asking, "Are you being serious?" I nodded my head "yes" as she searched my eyes to make sure I wasn't razzing her, that I wasn't in one of my silly, joking moods. "Completely serious," I finished, adding, "you went above and beyond making those kids feel comfortable while their mother was here getting treated. Well done."

She thanked me for acknowledging her work and then we both continued on with our work.

Before any nay-sayers speak up, I know, I know--we're not running a baby-sitting service in the ER. Flipping that coin, some might dare say that every patient deserves this customized, special treatment. Sometimes the ER setting is so damn busy, though, that despite our best intentions, we just don't have the time to devote to these extended acts of kindness. During those times when the hallways are packed with patients and chaos is smacking us around, we are focused on delivering excellent medical care. Quickly. At these times, unfortunately, the extra kindness and compassion that most of us strive to give may be sacrificed, pushed to the sidelines, to ensure our patients, sometimes with dire illnesses, receive quick, prompt emergency care.

In the midst of that day's shift, an act like Lindsey's served as a reminder of why most of us entered the medical field in the first place--to take care of patients and their families. To provide them the same treatment we would want our family to receive. To not get caught up in the rush of things and remember to be kind and extend our compassionate selves.

Lindsey didn't need to get the kids popsicles and situate them to watch TV. But she did. She didn't need to get them pudding, coloring books, stickers, crayons, and set them up outside of their mother's room, offering up her precious counter workspace and stools. But she did. Jamie didn't need the hassle of trying to accomplish her secretarial work while keeping an eye on the two kids sitting beside her. But she did it without complaint.

Despite the chaos, they extended themselves. And although Mom didn't demand it or expect it, I'm sure she appreciated the kindness shown to her kids while she lay ill in bed. What parent wouldn't?

So, a salute to Lindsey and Jamie. Makes me proud to be on their team.

I hope they treat themselves to a popsicle and pudding for a job well done.

As always, big thanks for reading. Next post will be Friday, April 2. Hope your week is going well. Until then...