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.

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 Where the Patients Taught Me

(Disclaimer: As per usual, identifying information has been changed or omitted.)

I’m lucky enough that my school recognizes the importance of learning from patients and their families, and as such, organizes a home visit for each student with the family of a child with some type of developmental disability. At my orientation for pediatrics, I was handed a slip of paper that detailed William’s disability: he was a teenager with incredible mental disability and minimal language and toilet training skills, but no working diagnosis.

With my almost nonexistent experience working with disabilities, I was perhaps more than just slightly nervous for the encounter, which took place one evening after my clinical responsibilities. I spent the ride to the house contemplating what questions should be asked and how to ask such sensitive questions in a respectful manner. I wondered how difficult it’d be to interact with William and his family.

But Mr. and Mrs. B and William were waiting for us with open arms and dinner on the table.  William, a small, thin boy for his age, smiled shyly at us, giggling and offering a hand for a high five when prompted.

After negotiating that William could have a soda with dinner as a reward for successful toileting earlier that day, we sat down to dinner, and the floodgates opened. Interrupted only by William’s prompting for certain stories to be told, Mr. and Mrs. B began pouring their hearts out, recounting countless experiences with doctors and the community and their son, providing more lessons to me than they could ever know.

I was reminded, once again, the importance of just listening: Mrs. B couldn’t thank us enough for letting her “gripe” about her daily stresses in dealing with a child that is trapped at the level of a toddler, the kind she feels guilty constantly burdening friends and family with.

I was reminded that often parents know best, especially with children who aren’t quite “normal.” They recounted a particularly scary period when William was nauseous and acting very tired, laying down on the floor at every opportunity. Despite the parents’ insistence that something was wrong with the shunt in his brain, the physicians sent them away since William wasn’t demonstrating typical signs of a headache, the most common symptom of such an issue. “But he wouldn’t know to hold his head when it hurt,” Mr. B explained, and it would later be found that he was leaking fluid from his brain.

I was reminded how scary it can be to not know a diagnosis, and how important it is to be honest with the parents, even when the news is not ideal. Time can be so hard to come by in medicine, but with tough diagnoses (or lack thereof), it’s SO important to take the time to answer the family’s questions and help them anticipate what is to come.

I was reminded of the fundamental goodness and acceptance of our society. I was concerned we’d hear heartwrenching stories of classmates who bullied William because they never made it past the drooling and lack of communication, but instead, Mr. and Mrs. B relayed countless stories of high school classmates of William’s who take him to baseball games, or of the community members who love to observe William’s enthusiasm at sporting events. William has even had the opportunity to meet some local celebrities, and beamed as he showed me his picture with our hometeam NFL quarterback.

I was reminded that physicians are often the first link to resources for care outside of the office, and that they should remain aware of the various tricks to save money or improve quality of life for these patients. Mrs. B was grateful for those who had taken the time to help connect her to other services to benefit William and the family.

But above all else, I was in awe of the strength of the family. Despite rarely having time to themselves, Mr and Mrs B show no signs of resentment toward their son or their lifestyle, instead embracing and tackling the challenges that come with caring for a disabled son day to day. The love and support within the family was palpable, even among William’s siblings, who acknowledge lovingly he’s just as annoying as anyone else’s brother.

So William and family: this one’s for you. Thank you so much for welcoming me into your home, providing me a home-cooked meal, and allowing me to see into your life in a way that will forever change how I approach my patients, but thank you mostly for allowing me the chance to get to know a happy-go-lucky, smiling, welcoming young man with a fervent love for M&Ms and sports.

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Side note: Yes, I’m alive. I managed to survive pediatrics, just barely, and I just started my family medicine rotation, but we’ll talk about that more later.

Until then,

K