A patient arrives at an emergency department suffering from a serious illness. His initial contact, a triage nurse, must quickly determine a number of things:~ There can be dire consequences when patients and health care providers don't speak the same language.
Is he a Level 1 patient with a migraine or is he at Level 5 and having a major heart attack? What's his medical history? Is he allergic to any medications?
There are also consent forms to fill out, medicines to explain, medical procedures that need to be communicated and accurately explained.
The catch: The patient doesn't speak the same language as the doctors, nurses and administrators.
This anxiety-provoking scenario plays out routinely in hospitals across the United States, and "we are only in our infancy in addressing the matter," says Dr. Val Warhaft, who has dealt with hospital language barriers firsthand for more than 25 years.
"As an emergency department physician working at two in the morning, having someone with whom I cannot communicate with is very, very risky," says Warhaft, chief medical officer of Emergent Medical Associates, an organization that manages the emergency departments of several hospitals in southern California. "There are overt life-threatening, and, I'm sorry to say, untoward outcomes that have occurred clearly as a result of the inability to communicate."
A 2002 study conducted by Health Access, a not-for-profit health care reform advocacy group in California, highlighted some blunders attributable to language barriers.
Like the elderly Russian man who was instructed to undergo a battery of expensive tests for angina after an emergency room physician misunderstood his complaints of "urgina" -- Russian for sore throat. Or the migrant worker from Oaxaca, Mexico, who was committed to an Oregon psychiatric ward as a paranoid schizophrenic, only to be released two years later after it was discovered that he was simply speaking an Indian dialect.
What about fatal mistakes? Amy Wilson-Stronks, a health services researcher at the Joint Commission on Accreditation of Healthcare Organizations, says they do occur, but it's hard to quantify how often. Preventable deaths are a sensitive issue, she says, because health-care organizations don't want to be identified as providing lesser care to certain people.
By law, hospitals are required to provide free language services to patients. Romana Hasnain-Wynia of the Health Research and Educational Trust, an affiliate of the American Hospital Association, says most use a combination of telephonic services, staff and freelance interpreters and interpretation agencies.
Many employ bilingual staff to help alleviate the burden, but Warhaft says that comes at a cost.
"If I need to call down an intensive care unit nurse because she's the only one in the hospital who speaks a particular language, she must drop her duties, find herself down to the emergency department and help me communicate with my patient," Warhaft says. "She's a very expensive employee being paid to do one thing -- now she's doing another."
The use of family members or friends is a risky alternative since they're more prone to commit errors, according to a 2001 study published in the journal Pediatrics. Such interpreters can also be insufficiently precise.
"It can't just be somebody who's going to translate, 'You know, I've been feeling better over the last three weeks,' into 'She feels better,"' says Wilson-Stronks.
Wilson-Stronks says ad-hoc interpreters can stifle the exchange of vital information: "Is the patient really going to be forthcoming about, for example, a STD, if their son or daughter is interpreting for them?"
Hospitals don't only have to decide how to provide translation services. They also have to figure out how to pay for them.
For most hospitals, that money comes out of their own budgets, with only 3 percent getting direct reimbursement -- mostly through Medicaid -- according to a 2006 national survey conducted by the Health Research and Educational Trust, or HRET.
Hasnain-Wynia says determining the annual cost to hospitals is difficult because most don't have a line item specifically for language services. Much of the cost, she says, is being absorbed by a multiple areas in the hospital.
"This is challenging because it's considered an unfunded mandate and it can be very expensive, but conversely, a medical error or a lawsuit can also be very expensive," Wilson-Stronks says.
A peek at Census figures suggests this challenge isn't going away.
According to 2000 figures, 18 percent of the total population aged 5 and over -- that's 47 million people -- speaks a language other than English at home, up from 14 percent in 1990 and 11 percent in 1980. And with this shift comes an increased demand for hospital language services.
The 2006 HRET survey found that 63 percent of hospitals encountered patients with limited English proficiency either daily or weekly, while another 17 percent reported monthly encounters.
The survey also showed that 89 percent of urban hospitals had frequent encounters with limited English proficiency patients. The proportion of rural hospitals -- 66 percent -- is smaller, but not insubstantial.
"There's always been this kind of perception that this is really an urban issue for big cities -- like New York, Chicago, San Francisco -- but not so much an issue in rural communities," says Hasnain-Wynia, lead author of the study.
Warhaft recently joined the board of Language Access Network, an Ohio-based company that hopes to address some of the language problem through real-time video technology.
Last year the company began contacting hospitals in California, Florida and Ohio to introduce them to MARTTI (My Accessible Real-time Trusted Interpreter), a portable unit that connects doctors, nurses and patients with interpreters in Columbus -- 40 people covering 100 languages, including sign language.
"We're our own little United Nations here," CEO Michael Guirlinger says.
The wireless unit on wheels was built with simplicity in mind, Guirlinger says. Health care providers push one button and are instantly connected via a 19-inch screen to an operator, who then refers them to an appropriate interpreter. If physicians are unable to identify a patient's language, they can call up a globe or flags that the person can point to.
It's a step-up from the telephonic interpretation technology that most hospitals rely on, says Francis Richardson, vice president of inpatient services at Mercy Hospital in Miami.
As a nurse at Mercy, where the MARRTI system was recently installed, Richardson says being able to pick up on facial expressions and hand gestures greatly benefits the quality of health care.
But even this impressive innovation has its flaws. Barbara Lovejoy, a nurse at Mountainside Hospital in New Jersey, wonders if adding a face to the anonymous phone voice might make patients less willing to share intimate information.
"In my department we get real explicit with a lot of our instructions -- telling them about what's going to happen when they go home after they've had a baby," Lovejoy says. "Now if you have a male translator, it might be a little weird for them."