Informed Consent

It would be my last call of the day. I didn't really want to go - I'd been dispatching all afternoon, when my coworker called me and passive-aggressively asked if I knew that we were now closing dispatch at 3:30 instead of 4. She didn't say so, but knowing her, she wanted me to take the call that had just come in. We had to go in order, and if I didn't get back in the pool, she'd be up next. I fumed in the hallway as I waited for the elevator about how bossy she was, but the second I arrived on scene, I was grateful I'd come.

At the bedside, along with about 3 nurses, was a handsome, strong-looking young surgeon practically shouting at a similarly young, strong-looking brown man in a hospital bed. "USTED PUEDE COMER COSAS COMO CAMARONES, MARISCO?" I was impressed by his decent vocabulary and grammar, but he looked pretty intimidating. I wasn't sure yet if this was my patient, but decided I didn't care. There was a good chance it was, and either way, this man deserved better communication. So I approached the bed and, projecting my voice above the machines, side-conversations, and the loud surgeon said, "Need an interpreter?" One of the nurses turned around and said, "Oh, perfect timing!" - as if I'd arrived by accident. I wondered who had requested an interpreter, and, for the millionth time, why most everyone else seemed to think they could do without one. The surgeon said, with relief on his face, "Oh, great, yeah, here's someone who's trained, let the professional do it." He sped off and I took his place at the head of the bed. Clearly someone had strongarmed him into helping them "get by." Still, I was grateful for his endorsement.

The nurses took him through their usual pre-operative questions: are you allergic to anything? when was the last time you ate or drank anything? etc. The surgeon came by with the signed consent to say that there were "a few things I had to add, and I need you to initial them - unfortunately they make me do that". He was apologetic, I think because the man found it so difficult to use his hands. Obviously, whoever had gone through the consent initially had done a rush job.

In case you're not familiar with consents for surgery, a consent contains several key elements: benefits of, risks of, and alternatives to the procedure are the most basic ones. The forms I've interpreted also often contain a diagnosis, who's performing the procedure, consent to receive blood if necessary, and disclaimers about video/camera recording and student presence in the operating room, among other things. Whoever had filled this consent out with the patient initially had forgotten to write in three things: the benefits of surgery, the name of the surgeon, and under risks, the possible need for further surgery. So we briefly went through the consent again. The doctor explained that the benefits would be to reduce pain and prevent the joint from stiffening, that it would require putting in a plate and some screws to keep the bones in place, and they would stay in for life, and that the patient might need further surgery at some point, but they couldn't predict that. This last is a blanket disclaimer that often gets thrown in as a way of saying, "something might go wrong at some future point, and you might need surgery again for it" It really doesn't mean anything more than "the future is unpredictable".

Our man initialed, painstakingly, in the places he was shown, and we continued to prep for surgery. The nurse stuck a Q-tip with a nasty looking brown substance up his nostrils to disinfect them, and had him brush his teeth with a mysterious liquid from a brown bottle. Finally she bent over him and asked, "Sir, do you have any questions for us?" Maybe it was something about her kind touch, or maybe he'd just had time while he was being disinfected to think about what he'd heard. In any case, he spoke up. "Si. Yo quiero saber porque no me entablillaron la mano, porque la verdad que prefiero que no me hagan esta operacion, pienso que seria mejor regresar a Mejico y encontrar un cura-huesos que me sane." He said more, but that was as far as I got in English before the nurse looked at me sternly and said, "So we need to get the surgeon to come back here." While she did, I took a second to marvel at what he'd said. "Yes. I want to know why they didn't splint my hand, because truthfully, I would rather not have this operation, I think it would be better for me to go back to Mexico and find a bone-healer to cure me."

It has become a fundamental principle of Western medicine that we don't do anything to the patient against their will. When we fill out consent forms, we often say, "but even if you sign this, you can change your mind at any time." Well, this man had.

Another surgeon on his team came to the bedside, and explained that they were planning to put his bones back where they need to be so they can heal. The man said something I've heard many times: "Bueno, si van a hacer lo que el dice, eso esta bien. Pero el otro doctor dijo que  me iban a poner una placa y unos tornillos, y que si no queda bien, me van a tener que rajar la mano otra vez, y si hacen eso y queda mal, un cura-huesos ya no me va a poder ayudar, como es normal." I repeated, in English, "Well, if you're going to do what you're saying, that's fine. But the other doctor said you were going to put in a plate and some screws, and that if it doesn't turn out right, you'd have to cut open my hand again, and if you do that and it doesn't work, a bone-healer won't be able to help me the normal way."
"I'm sorry sir," the doctor said, "I didn't mean to confuse you. We will put the bones in their right place, but then we need to put in a plate and some screws to make sure they stay there. So what the other doctor told you is true, too. Would that be ok?" I communicated this to the patient. By this time, the whole surgery team had arrived. The patient gave an uncertain, hesitant "Yeah..."
The doctors conferred "Has he had any medication yet?" one of them asked. The other shook his head. "What about his injuries?" "Well, he didn't hit his head, and there's no sign of a TBI" I knew that stood for traumatic brain injury. In a second I realized they were trying to decide if he was fully in possession of his wits or if they could operate anyway, for his own good, since they had written consent. As it turned out, there was no loophole.

So the head surgeon, who had filled out the consent earlier, clapped him on the shoulder, in a gentle, friendly way and asked, "What are you worried about?"
At that, the man really let loose. He began talking about his employer, and his worries about being out of work but having huge bills to pay, and worry about having to have a second operation and have even more to pay; how he would rather take care of this at home, but there was no money at home; how he'd never hurt his hand this way before, and really, he didn't get it- it didn't look that bad. At this point, he began to take off the brace he'd been wearing and inspected his arm dubiously. He'd seen guys on the farm back home twist their wrists in some terrible ways, and the bone-healer had straightened them out in 5 minutes.
I did my best to keep pace with him, and finally the doctor said, "I think you have some serious concerns about this surgery. My opinion is that operating is what's best for you, but at the end of the day it's your body, and I won't do anything you don't want to have done. So why don't we wait another day or two and we can talk more, and you can think it over. We can wait two days, and if you want the surgery then, I will do it." The patient seemed on the fence still, but after everything he'd said, the team knew they couldn't operate.

They wheeled him away, and I got called away to another patient. But I was amazed and oddly elated. The patient I'd just worked with chose not to have an operation that would assuredly improve his quality of life, and yet, I had a spring in my step. It took me a minute to realize what it was... I had just witnessed true informed consent.

So often the patients I work with have reservations or questions about what the medical team decides to do. So often they don't say them out loud, or are not fully listened to. But today, there was real communication. This man's voice and his worries were really and truly heard, and it filled me with a fierce joy. I really hope that he gets to sit down with someone and really talk about his reservations. I hope he does get the operation, and that his body returns to full functioning as soon as possible. But for that day, in that moment, it amazed me to see the whole machinery and process of the medical system come to a full stop to respect this young man's wishes. This young man, a laborer from the rancho (the backwoods of Mexico), who stood no chance of getting workman's comp from his employer, even though he was hurt on the job; this man who had more faith in the cura-huesos than in a first world medical procedure, the type of person who is so rarely listened to that many they have learned not to raise their voices or their questions - this man was listened to. It felt, just a little bit, like justice.

do mi sol

Today I spent time interpreting for a patient of ours who is what we call a "frequent flyer," meaning her condition requires her to be in and out of the hospital quite a bit. She's gearing up for a new treatment, and so there was a good bit of talking to do today. There have been some rough patches with this family: for a while there was some conflict between mother and daughter, complicated by the fact that the daughter has a learning disability, so we spent lots of time interpreting for social workers or psychologists who were trying to mediate, and I personally always walked into those sessions with a good bit of trepidation. It was difficult, too, because the daughter is fully bilingual, and takes pride in being able to speak English with the staff. That puts us as interpreters in the somewhat awkward position of interpreting the daughter's words to her mother - while she's judging us to see if we said what she would want to say. In the midst of a fight, that can be tough. Thankfully that rough patch is over, and today was a simple matter of education: relatively pleasant and straightforward.

Afterward, I went to visit the chapel, as I often do, just to think or play the piano, or pray or sing. I had sat down to the piano and was playing a song when I heard the telltale sounds of someone entering the quiet, green-carpeted space. The door handle clicked, swung open. I didn't turn to look until I'd finished the verse in the song. When I did, I was expecting to see someone random, briefly apologize for disturbing them, and leave. Instead, I saw the same family I'd just interpreted for.

"Toca el piano?" the mother asked me, "Do you play the piano?" "Yes, one or two songs, not much" I said in Spanish, for once not parroting her words in English. This seemed to give her confidence.  "Are you a Christian?" she asked, to which I replied that I was. "What church do you go to?" So I told her, and then her daughter piped up:"I want to know how to play the piano," she said. "Oh, yeah? Well, it's here if you ever want to practice," I said, not thinking about her upcoming treatment and how she wouldn't be able to, not sure what to say "it's always here." "Yes. I want to play the piano."

I looked at her and thought. This was the moment of truth. Or the moment where the sh*t hit the fan, depending on how you wanna look at it. It's one thing to exchange a few words, to be polite and not rude. It's something else entirely to actually interact. And then, I just went for it. "Ven," I said, "come on. I'll teach you one thing." I walked over to the piano, she followed, and I sat down on the bench next to her. I showed her how there is a pattern of three black keys, then two, then three, and how your hand goes at the beginning of the sequence of two. She learned to play from C up to E, on both hands, and since she was kinda going for it anyway, I showed her the arpeggio of C too. She was able to play those things, and before I left and went back to work I got to tell her in Spanish, "mira, ya sabes algo en el piano!" "Look, now you know something on the piano!"

Sitting there with her made my heart so happy! I've taught basic piano stuff to several of my cousins, and it was such a delight to do something so normal with her, without the awkwardness of talking over her, or for her mother, or about medical stuff. A relief from all the stressors I'm typically dealing with when I see her. The simple joys of teaching and music and encouragement. As I walked away I couldn't keep the giant smile from my face. It was good just to connect.

Le Felicito

You'd think that, if you get a call to go interpret in the trauma center in the emergency room, you'd be walking into a crazy, dire situation every time. Turns out that's not necessarily the case. Because of this, I've come to understand the word "trauma" not as "intense dramatic event" but more like "physical ailment that's not a disease process;" in other words, some kind of impact or accident that caused the person harm... like falling from something, or having something fall on you, getting mugged, or shot, or cut, or stabbed, or hit by a car, or sometimes even just having fallen down. One time I interpreted for a guy, a cook, who had shaved off some of his finger with a knife; but another time there was a mother/daughter pair who'd been in a bad car accident and held hands across their stretchers - which I say to point to the fact that, although it's all trauma, how chaotic and scary a case is can vary dramatically. The guy who chopped his finger had rigged his own tourniquet with a rubber band, and the surgeon was super impressed, so half the time I was interpreting compliments. You just never know what you're going to get.

Most recently my favorite encounter in the trauma center was with an older man (a patient) and the younger doctor who was admitting him to the hospital after a bad fall.

I had been bouncing back and forth between interpreting for this same patient and a couple others all afternoon, and they eventually made the decision to admit him. Over the course of several hours, with different technicians and providers, I had discovered him to be decorous, good-humored, and patient. He knew his own health problems well, and was a deliberate, clear storyteller; full of fancy words, jokes and good manners. So when the admitting doctor arrived, I was pleased to realize that he was a clear communicator as well.

He made eye contact with the man on the stretcher. Shook his hand. Asked what had happened to bring him to the hospital. He maintained eye contact and took notes as I first listened to the story (my third time), and then told it to him in English. He paused before asking his next question, then looked the man in the eye and spoke clearly, despite the fact that he was speaking English and couldn't be sure how much the patient would understand. He was even able to use gesture to great effect, something a surprising amount of people don't do well intuitively. As he went through his series of questions, I became gradually less and less of an obvious presence in their communication. It was one of those golden moments, the ones you always angle for, where you've actually faded to the background and the people you're serving have formed their own connection. It was beautiful to see. And the MD continued to ask clear, thorough questions and get clear, well-worded answers.

At the end of the interaction, they shook hands, the MD turned to thank me, and we both began to walk away. Then suddenly, the man on the stretcher said, "Le felicito!" I wasn't sure what he meant, so I looked at him, brow furrowed, and repeated it in English with a questioning tone "Con...gratulations?" He took the hint. "Le felicito, doctor, excelente trabajo. Muy cientifico!" Aha, I thought, that's what he means. "I congratulate you, doctor, excellent work. Very scientific!" At which the MD smiled and said "Thank you very much!" - which the patient understood. He then turned and thanked me, and we said our goodbyes.

The German-English dictionary I use tells me that the German word "sich verabschieden" is "to bid farewell" or "take your leave" or "say goodbye". The Spanish "despedirse" comes to about the same thing, but I wish there were a noun in English for the closing at the end of an interaction. Like "greeting" but for goodbyes. I've noticed that these types of formalities are much more important in hispanic/latinx culture than in US culture (although the US varies a lot, and so do hispanic/latinx cultures). An example, though, would be how when you enter a room, you have to greet every person in it. At a party or gathering, saludar can be quite an ordeal, especially if you're an introvert! But it's equally important when you leave, to take leave of every person. Not to do so can be insulting. But I digress.

The thing that was interesting and beautiful about this despedida interaction between patient and provider was that what the patient really meant with his "Le felicito, muy cientifico!" was "You were very thorough, I feel heard by you, I trust you, and think you'll do a good job of taking care of me." It was proof, to me, that it had really happened for these two: a therapeutic relationship, that bond of trust and mutual respect, had been established - in just minutes! It was a privilege to take part in that.