The One Lost in Translation

I can almost guarantee you this situation is happening in some hospital, somewhere, with some patient: the medical team walks in, asks a few simple questions in English, and gets the correct answers. The team then proceeds to explain the entire treatment plan in English, assuming that if the patient can respond to basic questions, they must have a grasp of the entire language.

My experiences this week have made me acutely aware of how dangerous this situation can actually be. When speaking to Guatemalans, I can demonstrate a reasonable grasp of Spanish, and often receive responses that are far more complex than I can fully understand. Sometimes, I just get the general gist of things. Other times, I make incorrect assumptions and miss the point altogether. Or worse, I may not have even the slightest idea what was said, but don’t feel comfortable enough (or can’t remember the words!) to ask them to slow down. But typically, I’m only trying to buy a bus ticket or understand my host brother’s new job, so a few words lost in translation are usually not a huge deal.

But when explaining a cancer diagnosis or the risks and benefits of a surgery, losing words in translation is not an option we can afford. I have no doubt there are patients for whom English is a struggle, but they may be too embarrassed or respectful to interrupt to remind us that they can only handle the basics. No wonder patients have difficulty complying with treatments, or even articulating what exactly their medical problems are.

Though I came to Guatemala to learn Spanish via cultural immersion, this trip is also a firsthand experience confirming the importance of using interpreters, avoiding assumptions, and checking to ensure patients are understanding their providers, regardless of language.

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The One with the Last Minute Lesson

“It’s your last day, right?” Dr. Family asked as we entered her office to start our lunch break. “I think it’s time to teach you how to balance work with real life. Come on.”

I tossed my stethoscope aside and scurried to catch up with her as she wordlessly exited her office and led me to her car. As she placed the keys into the ignition, the chorus of Nelly’s “Ride Wit Me” blasted through the car, and I stifled a giggle at the thought of my attending jamming out on her way to work.

“Are you up for ice cream for lunch? We can eat it on the beach…”

Ice cream? Beach? Now this is my kind of lesson.

And for thirty lovely, relaxing minutes on the sunny, warm waterfront, we indulged in peanut butter fudge ice cream. 

Lesson learned.

———-

For my new visitors (and old friends!), thanks for stopping by! I’m K, a fourth year medical student in the US who realized I recently had my 22nd and final first day of school EVER! Please take a look around (and maybe even subscribe or follow me on FB/Twitter), or hop on over to visit our lovely hostesses Emma and Jane to peruse some other fantastic medical blogs.

The One Where Water Poured Out His Nose

“Sir, why don’t you tell us a little about why you came in to the hospital,” Dr. Weekend prompts the elderly patient, despite having heard his story from the overnight resident.

“‘Cause my head hurt. I’m not dealin’ wit’ it. Tired of it,” he snaps, clapping one hand over his left temple. “And I was bein’ confused. I got locked outta my apartment all night!”

“Okay. So your head hurt and you were a little confused. Anything else?”

“And my nose keeps runnin’ and runnin’,” he offers.

“Well, we saw a bit of a sinus infection on your CT, so that would make sense. Is it both nostrils?” Dr. Weekend continues.

“Nah. It just be the left one,” he offers with a sniff.

My attending nods and asks him to sit up in his bed so that she can go through a quick neurological exam.

And he sits up. And that’s when I see it:

He scrambles to hold a tissue to his nose, but not before I notice several drips of watery liquid pouring from his nose. My concern for this man immediately picks up a notch, and I look incredulously from my attending to my resident for signs of worry or surprise. But they don’t react.

“My nose always be drippin’ worse when I sit up,” he notes, humoring the physicians as they walk him through the neuro exam.

“That’s probably your sinus infection,” Dr. Weekend says, patting his shoulder for reassurance.

Now, I’m a third year medical student, the lowest of the low on the medical totem pole. There’s hundreds of diagnoses I have yet to experience, but I have had a run-in with a sinus infection or five. And never ever have I seen anyone with mucus pouring out of their head like water from a pitcher.

Instinctively, I’m sure of it: that’s not mucus. Despite never having seen it, I’m willing to bet this man has CSF rhinorrhea, a condition where the fluid that provides cushion to the brain is leaking through a nostril.

And suddenly, I’m faced with a difficult task: raising the possibility that the attending might be wrong in a world where in many cases, the medical student speaks only when spoken to.

We step into the hallway, and I inhale sharply.

“Dr. Weekend? Is that really just a sinus infection?” I begin slowly.

She nods. “It’s on the CT. There’s a big infection right in that left sinus,” she says insistently.

“There’s nothing else that could be?” I prompt.

“It’s the infection,” she says, her tone effectively ending the conversation. “We need to get an LP on this guy.”

And so we walked away, with me making a mental note to bring it up with the day attending on Monday.

But I wouldn’t need to. By Monday, Dr. Days has already ordered the tests and confirmed that this nasal fluid is CSF, and this man’s brain is bulging out into his nasal cavity.

—————-

This situation raises the dangers of the current medical hierarchy. Though I realize in hearing stories from trainees past, medicine has become much more open to input from students and residents, there is still this dynamic where it becomes incredibly difficult for a student to point out some attendings’ mistakes or oversights without overstepping boundaries or risking a poor evaluation.

I keep wondering if I should have pushed the issue harder with Dr. Weekend or the weekend resident, but I’m pretty sure that they both would have justified the current opinion and shrugged mine off as a silly medical student idea. I have always feared the day when my mistake led to an adverse outcome for a patient, but I never considered the possibility of recognizing a problem and being unable to convince those in power that it was a reality.

I’m grateful this man got his diagnosis, but it terrifies me to think that he may not have or he may have gotten there only after a life-threatening event. If something terrible had happened, would it have been my fault for not doing something? What was I supposed to do in this situation?

Have any of you ever had to stand up to an attending or a physician above you in the rankings? If anyone has any advice on how to approach this type of situation, I’d love to hear it in the comments.

The One With the Psychiatry Study Day

Because you all really wanted to know what actually happens in my apartment when I claim to be studying all day… here’s the play-by-play, so you can even replicate it yourself!(Though I make no claims as to the success of these actions… replicate at your own risk!)

9:05 AM: Wake up feeling so incredibly grateful for sleeping in on that wonderful gem known as the WEEKEND.

9:07 AM: Realize that it’s not actually the weekend, it’s just the study day before a shelf exam. Buzzkill.

9:35 AM: Root through the freezer in an attempt to scrounge up an acceptable breakfast, since I’ve consumed most of my food in the two weeks since I’ve last grocery shopped. Decide that now is an appropriate time to rearrange the entire freezer in an effort to assess dinner possibilities for upcoming surgery rotation and make room for soon-to-be-assembled frozen crockpot meals.

9:56 AM: Settle on pumpkin Eggo waffles for breakfast. There are plenty of other meals today that can be healthy, right?

10:03 AM: Head to clerkship website to download the “Psychiatry Shelf Study Guide.” Pat myself on the back for initiating productivity so early in the morning.

10:17 AM: Remember that Modern Family was new last night, and I haven’t watched it yet. Remedy the situation.

10:41 AM: Hey, wasn’t it a new episode of How I Met Your Mother this week, too?

11:08 AM: HOLD UP. There’s going to be Boy Meets World sequel featuring Cory and Topanga’s daughter, and CORY is slated to play Mr. Feeny?!?!?!?! Mind. Blown. Must tell ALL friends.

My inner seventh grader took a moment to celebrate, just like this.

11:12 AM: It’s late enough for lunchtime, right? Hello, leftover fish burrito!

11:14 AM: Realize that my psychiatry shelf study guide is open behind my web browser.   Oh, right. Today’s a study day. Maybe I should attempt some semblance of productivity and read this study guide and do some practice questions. Maybe.

PSYCH PSYCH PSYCH PSYCH PSYCH

12:07 PM: You know what, Psychiatry? I’m going to multitask and catch up with some friends via online chat while I study. And listen to “Jazz for Reading” on Songza. How does that make YOU feel?

Oh, Michelle. I love your support.

12:50 PM: Dear NBME, Next time you make a shelf exam for Psychiatry, it’d be really, REALLY nice if it didn’t focus on neurology, which I have yet to complete. No love, K.

1:31 PM: Who thought it would be a good idea to have two very different medical problems and name them koro and kuru? WHY DID YOU DO THIS TO ME?!

Even Oprah thinks it’s a terrible plan.

2:45 PM: As an example of regression, “many medical students who return home act as if they are teenagers with regards to their parents or other hometown friends.” Geez, Lange. Tell me how you really feel. Before I have a mood swing and lock myself in my room with some emo punk music.

3:03 PM: Battle strong desire to complete online Christmas shopping before surgery rotation starts, which obviously means it needs to happen NOW and not this weekend. Spend the better part of an hour half writing explanations to psychiatry questions, and half compiling a list of loved ones who will be receiving gifts this year.

3:54 PM: Scramble out of my room immediately upon receiving text from my roommate that reads something along the lines of, “I’m making churros… do you want one?”

5:12 PM: Decide that my friend (A: “Good luck, good luck, good luck studying!”) is exhibiting signs of palilalia-ya-ya-ya-ya-ya. 

5:30 PM: Engage in a lengthy discussion about my upcoming surgery rotation with my roommate, who has already completed this block. Get simultaneously more excited AND more terrified to begin trauma surgery next week.

6:26 PM: Procrastinate reinitiating psychiatry work via workout session, even though it means changing out of pajamas. By the way, have I mentioned my new obsession with Blogilates?

7:23 PM: Make dinner. Honey pecan crusted salmon with caramelized leeks and carrots? A study day never tasted so good… even though I’m too antsy to wait for complete caramelization.

This is obviously what I did the entire time I was cooking.

8:35 PM: Realize it’s crunch time. Watch the video of that kid who gives the speech from Miracle for inspiration and hunker down for a few hours until bedtime.

…come 12 PM tomorrow, I’ll be midway through my third year and I have no idea how I got here.

Rx: One Boost of Confidence

“Mr. Smith, I know you’ve seen a lot of doctors in the past year. I was wondering if you had any advice on how I can be a good doctor for patients like you.”

“Honestly? Just keep doing what you’re doing. You’re already there.”

 

So grateful for interactions with the Mr. Smiths of the world: those patients who give more to you than you could possibly give to them.

Success is Like a Leaky Faucet

As a medical student, I am constantly learning… from books, from preceptors, from other students. But by far the best lessons are those from my patients themselves:

Mr. Farmer: Getting old… it’s not fun.

Me: Everyone in this place tells me not to get old.

Mr. F: Honey, you can try, but I don’t think it’s going to work. All you can do is NEVER smoke, only drink a little, work hard, and be happy.

Me: Got it. Good advice.

Mr. F: OH! And never go to bed mad. It’s like building a wall between you and Mr. Right. Nobody likes walls in bed.

Me: I’ll keep that in mind.

Mr. F: AND remember that success takes time. If you have a leaky faucet and it’s juuuuuust a drip, if you put a cup underneath it, it’ll fill eventually. Always remember the leaky faucet.

Drip, drip, drip.

——

Ms. Smith: Here’s my advice for you, honey. Do good now, and stay the hell away from pizza!

Apparently, pizza is bad.