22 July 2008

Consent

The patient was a hispanic male in his early twenties. He spoke not a word of English, and my Espanol is, as they say, pocito. The triage note said he had abdominal pain, but he couldn't give me any other useful information. There were no spanish-speakers working in the department, and some phone problems temporarily precluded the language line interpreters.

Fortunately, the diagnosis wasn't challenging: we did the "dolor aqui? dolor aqui?" game, and his right lower quadrant rebound tenderness and fever made the decision to order a CT for appendicitis a no-brainer. I was not at all surprised when it came back positive, and finally we were able to get an interpreter on the phone so I could get the rest of the history and explain to the patient the diagnosis and treatment plan.

I hate using interpreters - especially the phone ones. It's a cumbersome process of handing a phone back and forth, a slow and asychronous communication process. They are a part of my life, though, especially with our large asian and russian populations. Although I hate it, I have great respect for the folks on the other end of the line. I am fairly detailed and complex in the instructions and explanations I give patients, and I do not stint the non-english-speakers. I have always been impressed by the professionalism the interpreters bring to their job.

So for this patient, I explained what appendicitis was, that he would need surgery, described the surgery and recovery, and briefly outlined the potential complications. Basically I went through the whole consent process for surgery; although getting the final consent and signature is the surgeon's responsibility, I like to 'prep' patients to make the surgeon's job easier. All with the interpreter flawlessly going back and forth in the background. Finally, the translator broke the "fourth wall" and said to me, "Doctor, I am sorry to say that I do not think your patient understands what I am telling him. I explained that he would need surgery, and his response was, 'I'll eat anything you give me.' So I tried to explain what an operation is, several times, and all he has to say is that he isn't hungry but if you tell him he has to eat, he will eat anything you say. I am very sorry, but I really don't think he understands."

We tried again, several times, in very simple and graphic terms, including my drawing a dotted line on his abdomen at McBurney's point, but still the patient was unable to verbalize an understanding of what we were trying to do. It was freaking weird. Maybe he was just very simple, or the language thing could have been the problem, as he apparently spoke a dialect of spanish that sounded funny to the interpreter. He sat there with stoic indifference and simply failed to get it. "Yes, doctor, but I'm not hungry," he kept saying.

Aieee! Finally, I gave up. I called the surgeon, presented the case, and warned him that though I tried, he might have to work a little harder than usual at the consent. Thank god it's not my problem, I thought. I did my best.

With this job, every day it's something new.

9 comments:

Anonymous said...

Not uncommon. Down here in Mexifornia it seems that no one can speak English. Our Spanish speaking staff often come away confused because some of these dudes from Guatemala, or the interior native tribes of Mexico apparently speak something all to their own.

Jill said...

I have had that happen as well, and the patient was also from the interior of Mexico. But I think in that case, the patient had a family member who could translate effectively.

How do those people function here, if they can't even communicate with Spanish speakers?

pdx nurse said...

Did you ask the interpreter to ask him what language he did speak?

Obviously he spoke a Maya or other Indian language.

And why are you handing phones back and forth? Speaker phones work great with interpreters.

There must have been someone with this guy who could have been a bridge between his native tongue and Spanish. He didn't just wander into the ER on his own by chance.

Someone needed to take a few minutes to do some detective work.

No offense but your problem solving skills seem to be a little lacking.

Savage Henry said...

pdx Nurse, it pains me greatly to defend Doc Shadowfax.

However....

Saying his problem solving skills are lacking is ridiculous. I'd much rather have him doing things in the ER that only a doc can do, not chasing down an interpreter.

Plus, it's not really his problem.

Your comment lends credence to the saying that anytime someone says "no offense, but.." they are about to offend you.

No offense, pdx Nurse, but your statement was not the most intelligent thing I've ever read.

shadowfax said...

SH - thanks for sticking up for me.

PDX - bear in mind we did eventually get it worked out. That was the boring part of the story, and not my job (the surgical team handled it), so I left it off the post. I just let them know about the issues ahead of time. And we've tried speaker phones, but our ER is noisy enough (or the equipment we had was crappy enough) that it never really worked for us.

Anonymous said...

FYI and FWIW, about 45% of Guatemalans do not speak Spanish. They do speak one of several Mayan languages. If they do learn Spanish, it is rarely learned in school but on the street. Also, in Mexico, only about 20% of the population has the opportunity to go to high school, so their Spanish is not the best. Currently in the US, many Spanish speakers also no not learn Spanish in school, but on the street.

Nurse K said...

There are phones with two receivers that you can plug into the phone for interpreters so you and the patient can hear the interpreter at the same time. Not sure where you get them, but they exist and we have them.

Sometimes things not related to language barrier are blamed on language when, in fact, it has nothing to do with language. Maybe the patient is a little slow, for instance.

threejalapenos said...

Hehe, Nurse K I was thinking the exact same thing (about the patient being being a little slow on the uptake). Oh, and Shadowfox, umm, not that it's a big deal or anything, but it bugged me. It's poquito not pocito. Sorry, it just jumped out at me.

jz said...

--agree with using a speaker phone of high quality

--There are many variants of "consent". As you know, it is a process, not a signature. Your efforts are laudable, especially, the drawings.
At the lowest level, the patient often consents to paternalism.

At ideal levels, the consent is well informed and made without economic or other coercion.