"The Patient Is Deaf"

At my ER computer station, I signed on to treat my next patient, a 42 y.o. woman who had presented with abdominal pain and, just prior to arrival, had noticed some blood in her stools. Despite her complaints, her vital signs were stable.

I went to pick up the clipboard for Room 31, her room, when I noticed a bundle of 8 1/2" by 11" white copier paper trapped under its metal clip, the top page of the pile covered with a lot of rushed handwriting. Stuck to this top page was a pink Post-it.

I grabbed the clipboard, with all of these extra papers and pink Post-it, and walked to the station counter, setting the clipboard down on some open space. I grabbed the Post-it and read. "The patient is deaf." This explained all of the writing on the top page. Between our triage nurse and this patient's room nurse, a conversation must have occurred where the patient wrote all of her answers to the various questions asked on the paper.

I smiled to myself about how great our nurses are. Not only did they save me time by saving the written responses of the patient, but they also gave me a "heads-up" Post-it. In the event the nurse and I hadn't yet had a chance to talk about a patient, I welcome when they let me know about a patient's special needs or circumstances this way.

Reviewing the top page, I appreciated just how in-depth the nurses asked their questions. There was not much more I would need to review with this patient.

I walked into Room 31 to find a middle-aged woman lying on her left side, eyes closed, with her hospital gown loosely-tied at her back's nape. A scratchy, white hospital blanket covered her up to her elbows. Her hair was flat and matted, as if she had spent the last few days in bed with her pillow. An empty chair had been pulled up beside her cot on the side she was facing. The room was dimly-lit and, since the TV was off, a calming quiet pervaded the space.

Since I wasn't sure if she was napping, I gently nudged her toe until she opened her eyes and looked at me. I could see her initial fog of "Where am I?" lift before me.

"Hello, maam," I said, paying special attention to enunciating my words, "do you read lips?" She nodded her head "yes." I smiled at her and continued. "It's nice to meet you. My name is Dr. Jim," I said, pausing to spell out J...I...M in sign language for her, "and I will be your doctor today."

She smiled at me and asked for the clipboard. She wrote out "Do you sign?"

I nodded "no." "I can spell my name," I spoke, giving her my undivided attention, "and I can sign all the words to 'You Are My Sunshine'." I did a little of the first verse for her, which revealed her hearty, guttural, infectious laugh, the first verbalization I had heard from her.

I thought back to my kids' preschool teacher, a wonderful woman who had the foresight to recognize sign language as a fantastic learning tool at their age. Because Ms. Denise's own son was deaf, she had made learning sign language one of her top teaching priorities, a priority she has carried with her to her new elementary job. My kids are a part of a group of lucky kids who have benefited from her forward thinking.

After a few minutes of general conversation, with me speaking and her writing, I began asking her a few more detailed medical questions. She grabbed the clipboard and flipped over the first page, now writing on the second, clean page. "Can you wait until my husband comes out of the bathroom? He can speak." She continued writing. "He just got here."

I nodded my head "yes" while I spoke. "Absolutely." As if on cue, the curtain pulled back to the room and a middle-aged, medium-height man in jean shorts and a t-shirt with wispy thinning hair walked in. He gave his wife a genuine smile before turning his attention to me. "Hello, sir," I said, approaching him with my hand extended, "I'm Dr. Jim and I will be your wife's doctor today. Nice to meet you."

He too had watched my face intently as I spoke, but it wasn't until he answered me that I connected the dots. Slowly, with thickened syllables and deliberate slowness, he answered me back. "Nice to meet you." The patient's husband was deaf, too. Like his wife, he could read lips and sign. But when he answered, unlike his wife, he verbalized his words alongside his signing. Very impressively and adequately, I might add. After just a few words, I was able to adapt to his speaking skills.

Between the small-talk, the rest of my history-taking, and the physical exam, I was able to witness the magic of their relationship unfold. It was extraordinarily ordinary, watching this couple interact. I don't know what exactly I had expected, since this was the first time I had interacted in the ER setting with a deaf couple, but they were a typical married couple who, through their various forms of conversation, skillfully interrupted and joked with one another.

Standing on the patient's right side of her cot, with her husband on the left, I was pleasantly reminded, yet again, that we fellow humans, despite our individual differences, are more similar than what we sometimes recognize. That, in the end, we all want nothing more or less than our neighbor.

It was during the explanation of the rectal exam, between the husband and wife, that I saw just how typical and ordinary this couple was. With the nurse now in the room, I explained to both the patient and her husband the necessary reasons for the exam. I explained how the exam would be done and what we would be looking for. When I was done speaking, as the nurse and I began preparing for the exam, the husband began gently teasing the patient about the exam, making a ring with his left thumb and index finger and sliding his right index finger through, mimicking the exam. Laughing the whole time he was doing it.

Well, the patient (probably nervous about the exam) did not seem to appreciate her husband's attempts at humor and, before we knew it, there was a flurry of hand movements between these two that could only be interpreted as a full-fledged argument. It was fascinating to watch. Despite our presence, they argued for about twenty to thirty seconds before their hands calmed down. The husband, after giving his wife the last signed-word, spoke clearly to her. "I'm sorry." He wouldn't be teasing her about this exam again. Ever.

Tenderly, they entwined their hands. The same hands that had just finished an argument.

I walked up to both of them, smiling, my gloved-hands ready for action. Before initiating the exam, though, I held up my right index finger to them, asking them to wait. When, at last, the room's calm returned, I did what I knew would make us all smile again.

I signed "You Are My Sunshine." Laughter filled this deaf couple's room.

This patient ended up having a lower GI bleed. As a result of this, we admitted her and she had a colonoscopy that revealed a bleeding polyp that responded nicely to the GI team's interventions.

Sometimes, I can only shake my head at how lucky I am to be doing this ER physician thing. I signed up for this job, yeah, but I had not expected my personal interactions with patients and their families to be as fulfilling as it has been in my career. Maybe even more fulfilling than providing good emergency care. Sure, like any other job, there are times through a shift when the hassles can outweigh the good. But, after the privilege of meeting this amazing couple as well as similar patients, you tell me how the rest of that shift could be a bad one?

It couldn't.

As always, big thanks for reading. I hope you all have a great weekend. Emma update--today is day 11 of 17. Yesterday was Kakadu National Park and today she continues the visiting and learning of the Aboriginal people and their customs. How lucky is she! See you early next week...

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...