Electronic Health Reporter

Guest post by Matt Bramowicz, project coordinator, Translation Cloud LLC.

Consider this scenario: You rush into the hospital, your loved-one cradled in your arms. You had found them unconscious in the bathroom moments before and think you may know what had happened. You just have to tell the doctors so that they can treat them right away and save their life. Time is of the essence, though, and you fear the worst may happen if they don’t receive the right treatment immediately. The doctors run over and ask you over and over again, “What happened? Did they take anything? Do you know what is wrong?” You open your mouth to speak, but everything you say is met with confused looks. You can tell the doctors cannot understand anything you are saying. After multiple attempts, the doctors take your loved-one away into another room, knowing that they have not comprehended anything you were trying to tell them and are unsure what is wrong with your loved-one. You want to scream, because you know exactly what they need to do, but you can’t do anything about it. You gradually realize that this may be the last time you see your loved-one.

You may think it’s a scenario out of the Twilight Zone or some bad dream. However, it’s a regular occurrence for many people throughout this country.

Language barriers have long been an issue in the healthcare field. More than 46 million people in the United States do not speak English as their primary language, yet everyone needs medical care at one point or another. This language-gap can cause serious issues with miscommunication between the doctor and the patient, which can result in a lack of proper treatment and can even lead to potentially fatal medical-related errors.

Despite this serious issue, currently most hospitals provide only limited interpreting services, or more often than not, no services at all. In those circumstances, doctors must rely solely on the patient’s family members, friends or non-fluent bilingual staff members to help communicate with the patient or the patient’s family. These “ad hoc” interpreters are less likely to tell patients about medication side effects and more likely to misinterpret or omit questions asked by health care providers. This is not their fault, of course, as most individuals are not familiar with what information is pertinent, or even how to translate certain medical-related jargon. Despite their best efforts at being thorough, they may be unconsciously leaving out important details.

Even when things go as well as they can, many patients report a significantly lower patient and clinician satisfaction rate than others who have had the benefit of using effective interpretation methods. In worst case scenarios, ad hoc interpreters are significantly more likely to commit interpretation errors with potential or actual negative clinical consequences. In these cases, the limited communication provided by the ad hoc interpreters can end up being even worse than no communication at all.

For example, consider the case of Willie Ramirez. On Jan. 22, 1980, 18-year old Willie Ramirez was rushed to the hospital after experiencing intense pain in his head, and falling in and out of consciousness. By the time he got to the hospital, he was already in a comatose state and the doctors turned to his family to find out what had happened. Willie’s family spoke very little English, and they assumed his issue was because of something he ate, as the symptoms came on suddenly after eating a meal at Wendy’s. They used the Spanish word “intoxicado,” which in Cuba means there’s something wrong because of something you ate or drank, and has no relation to the English word “intoxicated,” which the doctors believed the family meant.

They treated him according to what they misinterpreted as a drug overdose, and transferred Willie to the ICU to recover. Little did the doctor’s know, but Willie’s problem was much more severe, as he was actually suffering from a misdiagnosed intracerebellar hemorrhage that continued to bleed for more than two days as he lay unconscious in the ICU. Had the misunderstanding not taken place and the neurosurgeon had been called, Willie could have walked out of the hospital completely recovered. However, since no neuro consult was ordered for two days while he lay unconscious in the ICU, significant damage continued to occur. Only after an attendee noticed symptoms of a neurological disorder was a CAT scan ordered, the hemorrhage diagnosed and a surgery performed. As a result, Willie ended up quadriplegic when he finally awoke.

While the physical and emotional damage caused to Willie and his family is certainly the worst part of this misunderstanding, the hospital itself also suffers when mistakes like this are made. As a result of this particular episode, the hospital was sued and Willie and his family were awarded $71 million.

Had an interpreter been present, the family could have communicated much more clearly with the doctors that Willie had not been drinking or taking drugs (he was actually vehemently opposed to both), and that the cause for his state must have been due to a much larger and more serious medical condition, in which case a neurologist would have been called in immediately.

Willie’s case is by no means a singular one. For instance, in another high-profile case, a 3-year-old girl was admitted to the emergency room with abdominal pain. Since her family did not speak English, there was a several hour delay in diagnosing her appendicitis, which later perforated and caused peritonitis, which required two wound site infections to be treated and a 30-day hospitalization. In another case, a hospital resident misinterpreted the Spanish phrase, “se pegó” as that the child patient was hit by someone else, instead of that she hit herself (when she fell off her tricycle). As a result, her sibling was incorrectly placed in child protective custody for a month because of to suspected child abuse by the parents.

While language barriers were first officially identified as a safety issue as far back as 2003, still not enough research has been conducted to get an accurate assessment of the correlation between language barrier issues and medical errors, so the true statistics between the two are still fuzzy. One of the major problems is that data are not routinely collected, let alone kept on file, of patients’ English proficiency.

Another major problem with using the patient’s family members to help interpret is that oftentimes the duty will rest on the children, as they are usually the first generation Americans in their family units and therefore tend to speak English with more regularity (from school and other social interactions) than their monolingual parents. However, due to their age and lack of other real-world knowledge, this does not usually tend to work out well. Recently, one study comparing hospital interpreters and ad hoc interpreters found that when an 11-year-old sibling acted as an interpreter during a pediatric visit, 84 percent of the 58 errors she committed had potential clinical consequences. Child interpreters are also less likely to have complete command of two languages, especially when it comes to complicated health-related terminology. Parents may also avoid discussing important, but more sensitive subjects, such as domestic violence, sexual issues, or drug and alcohol abuse in front of the child.

In an effort to curb the potential dangers inherent in language barriers in healthcare facilities, a Title VI guidance memorandum was issued by the Department of Health and Human Services (DHHS) Office of Civil Rights which stated that the denial or delay of medical care for patients with limited English proficiency due to language barriers constitutes a form of discrimination and requires Medicaid or Medicare recipients to provide adequate language assistance. While this has certainly helped to make a step in the right direction, all facilities must take it upon themselves to incorporate appropriate solutions, regardless of the extra expenditure.

In this day and age, there are no excuses to let interpreting needs fall to the back-burner, as a lot of translation and interpreting companies have stepped up to the plate to offer more cost effective and efficient solutions. One of those solutions that is gaining a lot of attention is Video Remote Interpretation (VRI), which can be utilized on PCs, laptops, tablets and even smartphones, cutting the cost of in-person interpreters by almost 66 percent.

Alex Buran, CEO of Translation Cloud, one of the most recent translation companies to offer VRI services utilizing the tablet platform, states, “We want to offer healthcare providers interpreting services that are all inclusive, more cost-effective and easy to use right off the bat. That’s why we decided on VRI utilizing the iPad platform as a base. This way, doctors can easily carry the device around from room to room, and have immediate interpreting services available should they need it. Doctors have a hard enough job as it is. They shouldn’t have to worry about language barriers and miscommunications.” While Translation Cloud is perhaps the newest translation company to adopt the technology, they certainly aren’t the only ones.

Many other companies such as Alta Language Services, CyraCom, InDemand Interpreting, Language Access Network and Stratus Video have all begun to focus on healthcare interpreting. As Stratus company president David Fetterolf says, “The healthcare industry spends about $2 billion a year on interpreting services, with so-called video remote interpreting (VRI) growing rapidly to take over at least half of that demand.”

While VRI may be fast becoming the most popular method, there are still plenty of other methods available, each with their own benefits and costs.  The following table shows some suggested options based on the needs of the patient.

Table 1. Suggested Options for Providing Adequate Language Services to Limited English Proficiency (LEP) Patients

*Patient and/or family members and clinician use headphones to communicate via an offsite interpreter.

As the table suggests, the most effective solutions involve a multilateral approach, dependent upon the specific needs of the patient and situation at hand. If a trained interpreter is present for face-to-face consultations, whether in person or via video remote interpretation, it may be fine to use machine translation services for written materials, including prescriptions. As long as the doctor verbally goes over the directions with the patient, and he/she determines that the patient understands the exact directions, there would be no need to require the extra expenditure to professionally translate the written material. However, if the doctor was not able to clarify all of the instructions with the patient in person, a professional translation of the written material would be required so the patient does not accidentally take the wrong dosage or misuse the medication.

With proper care and planning by both doctors and healthcare institutions, language barriers no longer have to be the nefarious obstacle they tend to be.