Working with Translators (trigger warning, infant death)

Last night I spent a little time with the 2nd year WWAMI students as they practiced doing medical interviews through an interpreter. I was just observing this simulation, so I did not share the story it reminded me of, but I’d like to share it here.

Picture a busy labor and delivery unit. I was a first year resident. As the only residents in our training hospital we were involved in most of the deliveries that occurred on that unit and there were typically about 12 deliveries during a given 30 hour shift. Often we would be hopping from one room to the next to triage, check someone’s progress or “catch a baby”. Sleep was rare and fleeting on our call nights.

On this particular day a young woman arrived in labor. She was about 20 years old, at term, having regular contractions, and the fetal heart tones were worrisome. She spoke only Spanish. We got the telephone interpreter on the line right away. The mother had a private physician in town she had been going to for prenatal care, but that physician was out of town and her care would therefore fall to the residents. This is not too unusual and residents were accustomed to covering such patients. What was unusual was that we had no records on the patient. All I had to go on was her verbal history. Through the telephone interpreter she and her young partner told me that they were at term and her labor had started recently. There were no complications to the pregnancy, but they had been told that the baby may have something wrong with his kidneys. I tried to tease out the nature of the problem. What else could they tell me? What was the nature of the condition? Did it have a name? Would it affect the baby’s health? They did not know. I learned what I could and reported back to my attending. We needed to perform an urgent cesarean section or we might lose it. I was not able to ascertain the nature of the kidney issue but things like misplaced or misshapen kidneys seemed likely. Given the nature of the fetal heart tones pattern our pediatrics team was called in to be at the delivery. We consented the patient for c-section and rolled her back. We skillfully and efficiently delivered that baby through her pristine skin. The baby was not breathing. The baby was limp. The baby needed resuscitation.

Newborn resuscitations are not unusual. We had one of our best pediatricians present along with our residency attending, another family medicine resident and multiple highly skilled RNs. In contrast to adult inpatient hospital resuscitation attempts (often called “code blues”), term neonates are almost guaranteed to survive. Aerate the lungs and all but the rarest cases will survive. This one did not. The pediatrician and other attendants ventilated the baby. They intubated the baby. They performed chest compressions on the baby and pushed medications on the baby. The baby died. We were all devastated.

Later we found out that the baby had no kidneys at all. The baby had total renal agenesis - a condition that is not compatible with life. No amount of medical heroics was ever going to save that baby. This was a fact known to the community physician who took care of this mother. This was a fact that was allegedly relayed to the mother in some way, but one that she did not embrace. This was a critical fact that should have been relayed to the delivering hospital far in advance of that fateful day.

I had not thought about this event until I watched the interpreter simulation. Where did we go wrong in this case? Was it a failure to communicate well through our translator? I suspect that may have been part of it, but there was more than a language barrier here. This mother wanted a miracle. She had been told her baby’s condition but she has her own belief system, experiences family influence and cultural influence that led her to consent to that “life saving” cesarean section.

The biggest failure in this case was probably the lack of transmission of medical data on such a case. That mom should have been given a copy of her records to keep with her. That record should have been sent to the delivering hospital ages ago. The birthplace needed to be aware this baby was out there. Would that have prevented the unnecessary cesarean? I cannot say, but it could have reduced the trauma that occurred that day. It could have changed everything that could be changed.

Let me tell you a contrasting story. Here in Pullman I once had a mother who was pregnant with a child who was also found to have a terminal condition on her 18 week ultrasound. This baby too could not survive. This mom too chose to carry that baby as long as she could. When she presented in labor sometime in her late second trimester we knew what to expect. This mother happend to be of the same faith as one of the nurses who was on rotation that day and that nurse happened to be one of the best nurses I have ever had the pleasure to work with. We delivered that beautiful baby girl to that mother’s arms that day. Small, still, lifeless, misshapen from her genetic disorder, and beautiful. She had full and beautiful lips, an adorable little bottom and the softest skin. I can still picture her so clearly. Our wonderful RN smiled and pointed out these features to mom. We made prints of her feet. She was named. She was held. She was loved. There was sadness of course, but also a sense of peace.

In one story we have a patient who did not have any providers in the room who knew her medical history, her story or her belief system. We did not speak the same language. We did not have necessary data about her prenatal care. We traumatized her body and potentially her mind with an unnecessary procedure. In the other we adapted, through acceptance, to the unimaginable.

Much is made of “consent” in medicine. We try to consent people as best as we can. We list the risks and benefits. We cite statistics. But we have to be ok with the fact that no matter how hard we try, no matter what language we speak, there will always be things that are lost in translation. We just have to do our best to minimize that. So we carry on: we plug information into a flawed electronic medical record system, we converse with patients. We try to ask the right questions and give the right answers. We try to listen well and reflect back. We do our best. And we carry on.