Editor’s Note: The November-December issue of Health Affairs contains essays by a physician and a medical interpreter on the challenges and perils of navigating language gaps between medical providers and patients in the absence of a trained medical interpreter. The essays appear in the journal’s “Narrative Matters” section, which is supported by the W.K. Kellogg Foundation.
The post below by Gail Price-Wise explores the same themes as these “Narrative Matters” essays. Price-Wise sheds new light on the case of Willie Ramirez, one of the most well-known and tragic instances in which interpreting difficulties and cultural misunderstandings resulted in medical error.
On the evening of January 22nd, 1980, eighteen year old Willie Ramirez was out with a friend when he experienced a headache. He attributed it to the smell of gasoline in his friend’s car:
I tried to ignore it because I wanted to be with my friend, and it went away for a while. All of a sudden, I had a sharp pain. I grabbed the back of my head. I sat on the floor. It felt like someone was sticking a needle through my head. My friend helped me to my car. I knew I was going to my girlfriend’s house – it was closer than my house. I couldn’t see right. Everything looked like things were moving around. I tried to find back streets to find the shortest route. I passed her house, slammed on the brakes and turned around and parked. I stumbled out of the car. I fell against the fence. Then her mom came out of the house and helped me in. I think I went in and out of consciousness. I remember a white coat. I think they were slapping my face. They were yelling, “What did you take?! What did you take?!” When I woke up, I didn’t know where I was. I already had the surgery, but I didn’t know anything. I didn’t know I was in a hospital. I didn’t know I was quadriplegic.
Willie Ramirez was taken by ambulance to a South Florida hospital in a comatose state. He became quadriplegic as a result of a misdiagnosed intracerebellar hemorrhage that continued to bleed for more than two days as he lay unconscious in the hospital. In the course of the law suit, it was asserted that Willie could have walked out of the hospital had the neurosurgeon been called in earlier. No neuro consult was ordered for two days because the Emergency Room physician and the doctor covering Willie in the ICU erroneously believed that Willie had suffered an intentional drug overdose and had treated him accordingly. The misdiagnosis was based on the physical exam which initially pointed to a drug overdose, and on complete confusion regarding the medical history. At the heart of this confusion, was the Spanish word “intoxicado” which is NOT equivalent to the English word “intoxicated.”
‘Intoxicado’ And ‘Intoxicated': Similar In Sound, Very Different In Meaning
Among Cubans, “intoxicado” is kind of an all encompassing word that means there’s something wrong with you because of something you ate or drank. I ate something and now I have hives or an allergic reaction to the food or I’m nauseous. On the day Willie’s intracerebellar bleed began, he had lunch at a fast food restaurant, the newly opened Wendy’s. His mother and his girlfriend’s mother assumed that the severe headache he experienced that night was related to eating a bad hamburger at Wendy’s – that Willie was “intoxicado.”
There are various accounts as to when and with whom the word “intoxicado” was used. Four people came into contact with the paramedics and the emergency room doctor: Willie’s mother, Iberia; his 13 year old sister; his 15 year old girlfriend; and his girlfriend’s mother, Concha. Distress clouds Iberia’s face when she denies she used the word, “intoxicado.” I feel like grabbing her by the shoulders and saying, “If it was you, it’s ok. It wasn’t your fault. It was the responsibility of the hospital to ensure their doctors can communicate with patients.”
Only Concha admits to using the word, but she adds an important caveat. She insists she clarified to the ER doctor that there was no alcohol or drugs involved. Concha’s English is very difficult to understand. Her accent is thick. She pauses frequently to search for an appropriate English word. She often places the accent on the wrong syllable, distorting the word. But Concha is bold and outgoing and unafraid to speak in a foreign tongue. She’s worked hard to assimilate into America, desperately wishes to speak English like a native and is overconfident in her ability to do so. She informed me that since Iberia didn’t speak English, she spoke to the doctor – in English. She wanted to tell the doctor that the hamburger Willie ate made him sick: “I say him, doctor the amburger intoxiCAted him. I asplain him no alcol, no droogs.”
In spite of the emphasis on the wrong syllable, the clearly pronounced “intoxiCAted” is clearly distinguishable, one of the few words that stands out as she relays the story. As Concha speaks, I wondered why she would have added the part about “no drugs, no alcohol,” since 28 years ago she didn’t know what “intoxicated” means in English and would not have recognized the potential for confusion. In recounting the story, she may have added this caveat to calm her conscious. There’s no way of knowing since the depositions have long since been destroyed. But if she truly said “no alcol, no droogs”, her accent may have rendered the words incomprehensible to an English speaker.
Differing Memories And Cultural Confusion
The ER doctor recalls:
The paramedics brought in an 18 year old comatose male, with no apparent trauma. In those days, we didn’t have a CT scanner in our hospital. All I had was my experience to draw from. His respirations were labored and I thought he might have a respiratory arrest. I intubated him and got his breathing stabilized. He had pinpoint pupils, which can be caused by opioid intoxication. He had no focal neurological sign, no palsy, no blown pupil, nothing to suggest a space occupying lesion. Healthy, strapping kids don’t come into the ER comatose unless they’ve been in a car accident or had an overdose. I thought my conversation with the family confirmed the diagnosis – that he had taken an overdose of drugs. I remember coming into lobby. His mother was there and I spoke to her through an interpreter that accompanied the family. I had some trouble understanding them, but the “gist” of the conversation was that he was upset about a fight with his girlfriend and had taken drugs.
Willie’s sister remembers the conversation with the ER doctor differently:
I remember him very clearly. He was tall and thin and light colored. We Cubans think a lot of Americans look light colored, but he was particularly light. The ER doc said to my mom that he thought it was drugs – that Willie’s condition looked like a drug overdose. My Mom was really upset that they said it was drugs. My mom and I spoke to each other in Spanish. My brother was an all-star baseball player, an athlete. He was really concerned about taking care of his body. We couldn’t imagine that he would use drugs. But a doctor said it – and you tend to believe what a doctor says. So we didn’t protest. We didn’t tell him this was impossible – that Willie never took drugs. In front of the doctor, we just said to each other in Spanish, “This just cannot be true.”
Cultural differences complicated the language issue. The ER doctor did not consider that in certain cultures, people never contradict what an authority figure, like a doctor, has said. The doctor needed to engage the family in a deeper discussion to understand the family’s persepective – that Willie was strongly opposed to drugs and could therefore never suffer an intentional overdose. In my interview with Willie, he said, “I rarely even drank a beer. I was totally against drugs. In fact, I was afraid of them.” The family would have told this to the doctor if they had been put at ease to speak freely. This would certainly have required a professional interpreter.
In my interview with the ER doctor, he continues his version of the story, “If I had a Mom who said, “My son would NEVER use drugs,” I may have thought differently.”
The ER doctor believed Willie had a fight with his girlfriend that upset him to the point of taking drugs. In my interviews with them, Willie and his girlfriend each told me that they frequently argued. Like many adolescent romances, they would break up one day and get back together the next day. His girlfriend, who was 15 at the time, likely found this to be endlessly fascinating and may have relayed it to the ER doctor. Willie’s mother would have known that her son never took the spats seriously and that this discussion was simply a distraction from the relevant medical history. But she didn’t speak English and was therefore relegated to silence. Most of us would shudder to think that an adolescent girl chattering about her boyfriend could influence life and death decisions in a hospital. This is the power given to bilingual children whose parents don’t speak English.
Neither the ER doctor nor the family requested a professional medical interpreter because each side believed they were communicating adequately.
According to the 2006 American Community Survey of the US Census Bureau, nearly one in five Americans speak a language other than English at home. At least one in 11 people older than the age of five report that they speak English less than “very well.” In the absence of readily available professional medical interpreters, health care providers turn to people without adequate skills to interpret. Ad hoc interpreters defined as family members, friends, untrained staff, or strangers from the waiting room are significantly more likely to make mistakes and to omit valuable information when interpreting than are professional interpreters.
The Power Of Personal Experience
I’ve spent most of my professional career trying to improve health care services for cultural and linguistic minorities. Privately, I never understood what was so wrong with using a bilingual friend or family member to interpret, especially if the topic wasn’t of a personal nature – meaning sex, or bladder and bowel functions. I changed my mind when my stepmother suffered a vertebral fracture after being thrown from a horse while on vacation in French-speaking Guadeloupe. Unhappily, I was the only person who could interpret in the hospital. My French isn’t fluent, but I would guess that it’s better than the English spoken by many family members who are asked to interpret in US hospitals. The fear of a spinal cord injury added urgency to my attempts to accurately interpret a foreign language. “Does she have neurological damage or not?” I struggled to pronounce “neurological” in French and hoped they would understand me. The response: “There doesn’t appear to be any neurological damage.” I didn’t understand the French phrase for “there doesn’t appear to be” and asked the doctors several times to repeat it, as family members waited wide-eyed for me to interpret what was being said.
It’s easy to make serious errors when interpreting. If you don’t understand a word or two, it’s natural to skip that part and just interpret what you understand. You just convince yourself that the few missing words probably weren’t important anyway. Like the ER doctor in the Willie Ramirez case said, you can still get the “gist” of the conversation. As I interpreted for my step-mother is Guadeloupe, I was only missing the French words “there doesn’t appear to be” – followed by the words that were clear to me, “neurological damage.” In getting the “gist” I had a 50:50 chance of interpreting correctly, that there either was or wasn’t neurological damage.
Then there was the task of relaying her medical history. Like Willie, my stepmother had suffered a brain aneurysm as a young woman. I assumed this to be an important part of her history, but unfortunately, the word “aneurysm” had never come up in my high school French class. I struggled to explain and believed they understood what I was saying, but I didn’t know if they did. In the end, she recovered fully – in spite of the limitations of her ad hoc interpreter.
‘Embarazada’ Versus “Embarrassed” And Other Translation Pitfalls
There are lots of pitfalls to avoid when interpreting. Particularly dangerous are false cognates, which are words like “intoxicado” that sound the same in both languages, but mean something different. “Embarazada” in Spanish does not mean embarrassed. It means pregnant. Imagine the woman in her first trimester struggling to explain her condition to the ER staff in her rudimentary English, “I am embaras.” Because of this word, a fetus might be exposed to harmful x-rays or drugs.
It’s also easy to simply be offensive. “Excitado” in Spanish is only used to denote sexual arousal. One would not be “excitado” about seeing an old friend – except if that friend is a real or imagined sexual partner. In English, “he is a character,” is different from “he has character.” “I am boring” is easily confused with “I am bored.” These expressions cannot be translated word for word because they won’t make any sense in other languages. “Caliente” means, “hot” in Spanish, but, like “excitado” is often used to refer to sexual arousal, or to food at a high temperature. It would be inappropriate to call yourself “caliente” in a doctor’s office, but you could say that your feverish child feels “caliente” to the touch.
One 2-year-old girl with a clavicular fracture was mistakenly placed in child protective custody for suspected abuse as a result of such a mistake. In the absence of an interpreter, a medical resident who may have spoken some Spanish misunderstood “se pegó” to mean the girl was “hit by someone else” instead of the girl “hit herself” when she fell off her tricycle. To a non-Spanish speaker, such an error would seem highly unlikely, but in fact, both translations for “se pegó” – “she hit herself” and “she was hit” are correct. In this situation, a medical resident who spoke some Spanish was worse than a provider who spoke no Spanish. A professional interpreter was needed to glean the correct meaning from the context. Errors in interpretation occur frequently, because it takes years to learn the nuances of a language.
Willie Ramirez: Conclusion And Aftermath
As a result of the miscommunication, Willie Ramirez was admitted to the intensive care unit with a diagnosis of “probable intentional drug overdose.” The attending physician did not question the diagnosis. Willie’s mother recalls that he had to be restrained because he was pulling out tubes with arms that still worked. After nearly two days, the attending physician recognized that Willie was no longer moving his arms and called in a neurologist who found a serious loss of eye function, indicating brain damage. The left lateral rectus muscle, which normally causes the eye to look to the side, was no longer working, leaving the medial rectus muscle unbalanced. The result was that Willie appeared to be looking at his nose, at least with his left eye.
During the exam, Willie experienced a respiratory arrest. He was put on a respirator and whisked away to one of the few hospitals in South Florida that had a CT scanner in 1980. The scan revealed a left intracerebellar hematoma with brain-stem compression, and an acute subdural hematoma. Emergency surgery was performed but it was too late to prevent the brain damage that left Willie quadriplegic. The law suit resulted in a settlement over Willie’s lifetime of approximately $71 million, assuming he lives to age 74.
There are other casualties in this story. Willie’s family and friends who tried to explain what was wrong with him and the doctors who tried to diagnose and treat him carry enormous sorrow, not only for Willie’s tragic loss of function, but for the painful thought that it didn’t have to be. In the words of the attending physician 28 years after the event, “You don’t know the agony of being blamed for something like this.”