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The Art of Medicine

Common language

Katers, Laura A. MCHS, MS, PA-C

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Journal of the American Academy of Physician Assistants: January 2021 - Volume 34 - Issue 1 - p 58
doi: 10.1097/01.JAA.0000723972.94123.e8
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The woman's pain didn't match the procedure she had—a sensitive dilation of the bile ducts to prevent obstruction from a cancer. I'd met her on previous admissions for the same procedure, but her pain was never this severe. She was my first patient on night rounds and although her charted pain scores for the day were a solid and severe 10/10 across the board, the comment I heard was, “Oh, she's fine. Hasn't asked for anything. She's been on her phone texting all day.”

I peeked into the patient's room through the clear glass dividing us, and sure enough, she was texting vigorously, like someone emphatically engaged in a video game. But she didn't look fine; her young face was lined and tense.

“Has anyone used a translator to see how she's doing?” I asked.

“Well, no. She seems okay,” came the reply.

I knew that none of us was really okay. After all, it was election season, fire season, and before the first influenza season in the midst of COVID. Housebound due to hazardous air quality, I was hungry for human contact and increasingly despondent over the loss of human, animal, and plant life from wildfires, and the myriad of other heartbreaks in the world I could do little about. I took stock of this global despair as it rippled across other faces as well and, in some cases, led to a mild dissociation that was becoming a coping tool for so many. I learned to never assume, but instead always ask: “Are you okay?”

I knocked softly as I walked into the patient's room and fired up a tablet to video-link us to a translator. Like anyone with a complex or chronic medical condition, my patient had little choice but to learn and try to make sense of the words of her disease and the medicine to treat it. And although she had an excellent command of the English language, it was not her first language, and ethics and optimal patient care would, at minimum, require offering translation for difficult or complex medical conversations.

As soon as the translator came online, my patient sat upright and covered her face with both hands, a sharp inhalation followed by a nearly silent exhalation shaking her small frame. I was reminded that not all words translate fluidly from one language to another—words like nostalgia, or frustration, or fear. Yet, her emotional expression of fear was so starkly palpable and vivid I couldn't imagine anyone missing it for what it was.

She recognized me, but it was the translator she cried out to. A string of sounds, words both melodious and rigid, pierced the space between us as they conversed. Finally, the translator, now with tears in his eyes as well, asked, “How long does she have?”

Of all the words this patient knew, “metastatic” was the one most feared. I learned that after my patient's procedure that morning this word landed lazily in the air above her, exchanged between people who assumed she didn't hear it, didn't know it, or perhaps wouldn't understand. Worse, a word that wasn't true. “I felt I was already dead, a ghost in a bed!” she cried out again.

I discovered the woman was not texting loved ones because she was fine or playing video games her teenage son had taught her, but making funeral arrangements, convinced she'd never leave the hospital. All of the texts were her final goodbyes.

How could it be that her silence had been perceived as relief? How had no one asked about her pain? But I knew, there were more patients, stresses, deadlines to complete and orders to enter, and we have to rely in part on our patients to be their own advocates. For many, however, we are the advocates, even more so for those who don't know how to or can't speak up. I called the care team, who arrived bedside to reassure her that the word “metastatic” was not a word meant for her.

When I arrived the next night, I visited her room first. Knowing she was unlikely to die soon and most assuredly not in the hospital, she appeared relaxed, her pain score down from a 10 to a tolerable 4 without any changes to her pain regimen. She texted her family with a bright smile and glistening eyes. When the translator came online, stories were shared and there was laughter that enveloped me as well as “happy” was one of the most translatable words and expressions of all.

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