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Healing Needs Understanding

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This is from the New England Journal of Medicine. It is not about illegal immigration and that particular political battle raging in the advanced world today. It is not about Spanish speakers although there are a lot in the U.S. and these examples use Spanish. This is about the plethora of languages available in the world and the problems that interpretation and translation have in a medical setting. It is a serious problem because medical emergencies (and unrecognized emergencies) are, inherently, serious problems where misinterpretations, bad translations, and cultural differences can mean needless suffering, death, and, in the US especially, massive law suits.

The mother went on. "A mí me da miedo porque el lo que estaba mareado, mareado, mareado y no tenía fiebre ni nada." (I'm scared because he's dizzy, dizzy, dizzy, and he didn't have fever or anything.)

Turning to Raul, the physician asked, "OK, so she's saying you look kind of yellow, is that what she's saying?"

Raul interpreted for his mother: "Es que si me vi amarillo?" (Is it that I looked yellow?)

"Estaba como mareado, como pálido" (You were like dizzy, like pale), his mother replied.

Raul turned back to the doctor. "Like I was like paralyzed, something like that," he said.

Watching Mexican TV and movies in English with Spanish sub-titles I have begun to see the difficulties in translating even simple conversations. Medical symptoms and the often amorphous feelings that a good diagnostician can barely turn into a firm diagnosis must be incredibly difficult.

This kind of article is going to bring out the xenophobes and isolationists crying about immigrants stealing "our" medical services. That is not the point. It needs another venue to be addressed. The New England Journal article is directed at the difficulties of dealing with people who use all languages. If Spanish is a problem near the border, what must Serbian be in Ohio or Chinese in Dubuque?

If Raul received inappropriate care owing to his misinterpretation, he would not be alone. One interpreter, mistranslating for a nurse practitioner, told the mother of a seven-year-old girl with otitis media to put (oral) amoxicillin "in the ears." In another case, a Spanish-speaking woman told a resident that her two-year-old had "hit herself" when she fell off her tricycle; the resident misinterpreted two words, understood the fracture to have resulted from abuse, and contacted the Department of Social Services (DSS). DSS sent a worker who, without an interpreter present, had the mother sign over custody of her two children. Clearly, catastrophes can and do result from such miscommunication.

Chinatown. 1925.

Some 49.6 million Americans (18.7 percent of U.S. residents) speak a language other than English at home; 22.3 million (8.4 percent) have limited English proficiency, speaking English less than "very well," according to self-ratings. Between 1990 and 2000, the number of Americans who spoke a language other than English at home grew by 15.1 million (a 47 percent increase), and the number with limited English proficiency grew by 7.3 million (a 53 percent increase, see graph). The numbers are particularly high in some places: in 2000, 40 percent of Californians and 75 percent of Miami residents spoke a language other than English at home, and 20 percent of Californians and 47 percent of Miami residents had limited English proficiency.

Yet many patients who need medical interpreters have no access to them. According to one study, no interpreter was used in 46 percent of emergency department cases involving patients with limited English proficiency. Few clinicians receive training in working with interpreters; only 23 percent of U.S. teaching hospitals provide any such training, and most of these make it optional. Data collection on patients' primary language and English proficiency is frequently inadequate or nonexistent. Although no federal statutes require the collection of such information, no statute prohibits it, either.

This is part of a much-needed article in the respected journal, The New England Journal Of Medicine, (July 20, 2006) by Glenn Flores, M.D. The article also presents a case that could have been prevented and was, obviously, the fault of faulty translations and inadequate multi-lingual staffing. 

Inadequate communication can have tragic consequences: in one case, the misinterpretation of a single word led to a patient's delayed care and preventable quadriplegia. A Spanish-speaking 18-year-old had stumbled into his girlfriend's home, told her he was "intoxicado," and collapsed. When the girlfriend and her mother repeated the term, the non–Spanish-speaking paramedics took it to mean "intoxicated"; the intended meaning was "nauseated." After more than 36 hours in the hospital being worked up for a drug overdose, the comatose patient was reevaluated and given a diagnosis of intracerebellar hematoma with brain-stem compression and a subdural hematoma secondary to a ruptured artery. (The hospital ended up paying a $71 million malpractice settlement.)

Morality is not, sadly, the first thought of hospital administrators in these days of HMOs, insurance claims and forms, law suits and community pressures. However, $71 million could make some think differently about the need for adequate translation services and multi-lingual staff or just measures to provide translations without expensive staffing patterns.

After eight years here in Mexico with my cardiologist, who is wonderful (especially in light of this third world location), I understand the need for clearly understanding each other. Eight years ago I could hardly speak Spanish and he can read and write English but his conversational knowledge is dreadful. We survived the first years and are now friends and I trust him with medications and advice (surgery and equipment-related needs wait for trips to Miami). We still use Spanish first and back questionable words with gestures, English (where he has it or understands it) and joint forays into medical texts until we are sure that important points are fully understood. I have my doubts that busy, American practitioners take that kind of time and emergency personnel don't have that kind of time. When the paramedic says, "Where does it hurt? Can you move this?" or" What medications are you taking?" they need answers quickly that don't need interpretation.

"Madonna" by Lewis Hine. Ellis Island.

I am reminded also of the book, Interpreter of Maladies, where a tour guide in India describes his work translating for sick people who speak a different language in India to the doctor who treats them. A fine story and an interesting concept of how one translates words that are so difficult — those that try to describe exactly the amorphous symptoms of illnesses sometimes from one culture to another.

The next question and suggestion is to the IT, medical and linguistic worlds in general. "What can be developed to help with this problem that doesn't require massive multi-lingual staff? Computer programs at this time are not up to the chore. A young Mexican man recently asked me to buy a chip from the Mexican eBay equivalent using my credit card. He sent me an email using a translation program. I already knew what he wanted since his father had told me in Spanish. This was the computer translation:
hello gift francisco I am leonel wanted to know if it is possible that you make a purchase in the free market, it is a Tarjeta SIM doble Universal, the one that I comment him my dad in the afternoon. he has an approximate price of $190 pesos. thank you this it is the it paginates web.

Would you want the emergency room physician to understand you as well as this conveyed its message?

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