NO VOICE

I came into the patient room, and as soon as I introduced myself, the newly arrived niece’s face lit up into a big smile. Not because she knows me. She had never seen me before in her life. But her aunt had asked her to take off from work and come interpret for her uncle because they didn’t know the hospital was going to provide one. I assured them that they can request an interpreter as needed. It was part of hospital overhead, and not billed to patients. And for an inpatient, we could work with staff to set up a daily interpreter for doctor’s rounds and to check in with the patient to make sure things were clear. The family was both pleased and surprised, even though this patient had been hospitalized for some time.

While the patient’s core medical situation was safe and stable, there was a mounting list of frustrating, painful misunderstandings. To start, the patient’s wife and her niece had both taken off work today because someone with limited language skills had told the wife over the phone they had to fill out some financial paperwork by June 1st or they would have to pay the whole hospital bill themselves. So they dropped everything and rushed in to meet with the social worker, who told them that they actually have until July 1st, not June 1st, to fill out these forms. The niece took off immediately to see if she could cover part of her work shift. The wife stayed and was able to get needed guidance on where to deliver the financial forms and what kind of documentation to provide. As I interpreted for the social worker, and she asked open-ended questions about care, it became clear that there were other gaps in communication.

For example, the patient had been trying to tell the nurse since yesterday that it hurt his throat too much to have the voicing valve attached to his tracheotomy ventilator all the time. It was a lot more pressure and strain on his throat. He wanted it off right away. The patient had pointed at it and gestured; he had even written down “throat” in his language on a piece of paper, but the nurse could not understand what he wanted. The wife, who had been there some hours, had been trying to tell the nurse as well, but the nurse didn’t understand. And it hadn’t occurred to her to call us. It was not until I happened to be there for the social worker that we were able to get this communication completed. The patient had been straining his throat all night, trying to talk to his nurse, to no avail.

The patient is no longer able to fully close his eyes, so naturally they get very dry. He had been pointing to his eyes and across the room at a drawer all night, and painfully voicing as well, but no one would give him the eye drops, and he could not reach them from bed. Because the wife lives and works in their hometown a few hours away, she cannot sleep at the hospital except on her days off. So the patient is alone most of the time. I interpreted for the nurse that her patient was desperate to get the eye drops and the nurse clapped her hands and exclaimed, “Finally! So that’s what he was asking for! I was holding up all kinds of things but then he just shook his head to all of it!” The eye drops were not scheduled, but listed in the chart as to be provided upon request. Too bad that staff couldn’t understand his repeated requests. His eyes were bloodshot and burning.

The patient also had a quick meeting with a respiratory tech supervisor, because they wanted to take him outside and he was refusing. To complete this short conversation, he agreed to have the voicing valve put on, they upped his oxygen as appropriate while voicing, and he was able to share his concerns. He could finally explain that he was used to having a tank by his wheelchair, and a small ventilator on his lap. The supervisor was able to help him understand that what he was describing was their portable equipment used while transporting patients, while the equipment they were now offering could do everything, including adjusting the level of oxygen as needed, and carrying the full tank. When the patient finally understood that the setup this unit had would work just as well and he would be safe, his relief was palpable. Staff was also saying, “Oh, now we get it! We didn’t understand! We’re sorry!”

While the patient was able to voice, he told the social worker that he felt like this unit was really bad, and the staff didn’t know what they were doing. For example, he said, he was supposed to get physical therapy every day, but the therapist was just not showing up. The nurse who was in the room told him no, it was set for twice a week only. He argued his point over and over, very frustrated, and even quoted the physical therapist as saying EVERY day of the week. Then he named each day of the week, Monday-Tuesday-Wednesday etc. He counted them out on his fingers for more emphasis. She said every day! They then discovered that the physical therapist had told him (in broken language and by gesturing) that he should exercise his legs – himself – every day of the week, to gain strength and hopefully walk again. And he had misunderstood. I asked the nurse when the therapy was scheduled so we could provide an interpreter for better communication, and the nurse told me they don’t schedule therapy on this particular unit, but rather “they come when they come”.

Upon my arrival, as a natural result of so many prior misunderstandings, everything that was said to the patient was greeted with suspicion, frustration, and even disdain. In fact, when he first got his voice back, the nurse leaned down with a friendly smile and asked him, “So what were you trying to tell me all that time when you were mouthing something and gesturing for me to leave the room before, when we were alone?” And he glared at her through his red eyes and answered, “I am not going to repeat it!” But during my one hour there, as each of these issues got clarified, and some got resolved, things changed and shifted. He was able to hear the staff, and they were able to hear and respond to him. He finally had a voice again, and he was starting to see that things might improve.

Everyone sees things differently, but as interpreters we are unique in our simultaneous access to several points of view in several languages. People tend to see one piece of the mosaic and we tend to see a whole pattern. I overheard the nurse in the hall saying to her tech that she was having so much fun with this patient, because she was able to practice her second language, and he was correcting her. All the while, he had been begging to get off the voicing valve, and straining his throat. His eyes were burning and red and he could not get the drops, even when he pointed and gestured. His family members were losing work to come provide services that the hospital provides. He was worried about the burden on his family regarding the financial paperwork that is not even due for another month. He did not understand the new ventilator oxygen setup, or feel safe enough to go outside. He was anxiously awaiting the physical therapist, who was not coming. And he had things to say to that same happy nurse that do not bear repeating.

Through my amazing supervisor, the unit nurse manager was approached about these gaps in communication, and immediately became proactive. She set up a meeting with the key players on the care team that same day. And she set up a meeting with the patient for the following morning, with an interpreter. She planned to attend herself, to make sure the patient concerns were covered, and to clearly communicate the proposed plan of care and rehabilitation. And she agreed to schedule the physical therapy – with an interpreter – so he could understand and fully participate, including the work he needed to do on his own in his room, that would expedite his return home. And there will be a daily interpreter, just for half an hour, while the doctors make their rounds, so he would know the plan of care.

These were simple, small miscommunications that got resolved. None a medical emergency. None life-threatening. But the clarifications were so precious to the patient and family. So helpful to staff. So valuable in allowing a very sick, newly disabled person feel seen, and heard, and acknowledged. How precious? At the end of my shift, when we came back and informed him that he would get a daily interpreter for half an hour each morning, and told him about the team meeting with an interpreter, he actually, with the voicing off to save his throat, pointed to this interpreter, pointed to his heart, pointed to the room with a broad wave, and touched his heart again, with tears falling. We cannot truly fathom how transformative and healing good communication can be. It goes deep.

My new supervisor is working hard to collaborate with the various hospital units and set up better procedures so that patients are able to communicate with staff from the very beginning. And that is wonderful. The sad part to me, though, is that it would have taken less than an hour of interpreter time on patient’s first day to convey all his concerns. I wish so much that everyone in healthcare could fully grasp this. It is incumbent to implement best practices and have smooth patient transitions when someone new is getting set up on a hospital unit. Interpreter services is a small thing to provide, in the big picture. But for the individual under the blanket, it is huge. Let’s not leave patients without a voice. It matters.