Mitch Blunt

Covid-19

How COVID-19 Isolates Patients From Their Own Language

This summer I served for one week in the COVID ward at Parkland. With my lapsed Spanish, I still wonder how much was lost in translation.

Work this summer was interesting. I spent the third week of July in my job as an internal medicine physician at Parkland Memorial Hospital attending only to patients with COVID-19. Many of my fellow hospitalists, those who had been the first brave souls to volunteer, had already spent weeks doing so. While I’d offered my services, I’d been more hesitant in my response to the unknown. Prior to my one-week stint, my exposure to COVID patients had been limited to a smattering of night shifts. I would come in for a few hours, admit a handful of patients with coronavirus, check on the sicker existing ones, then return to my normal job of caring for patients with problems I’m used to dealing with: heart failure, kidney injury, cellulitis. I didn’t get a real sense of the differences in this new group of patients until I got to the slog of “doing COVID” for days in a row, day in and day out.

Almost immediately I was struck by how overwhelmingly Hispanic the patient makeup was. Moreover, out of the roughly 25 patients I cared for that week, only three spoke English. Parkland is a county hospital; on a typical day, perhaps a quarter of my patients are Spanish-speaking only. Certainly it has never been more than half. Twenty-two out of 25, or 88 percent, is so far of an outlier as to be a complete anomaly. (I’ve changed some minor patient details to protect identities, but this is an absolute fact.)

Normally, I can place an order for a Spanish interpreter, and one shows up, dressed in a uniform of black slacks and royal purple polo shirt (Parkland’s signature color), within the hour. I see all my Spanish-speaking patients in a row, walking from room to room, with the friendlier interpreters in step beside me, carrying on a conversation. I’ve gotten to know the translator staff. There’s a matriarch who has bad knees but likes to take the stairs anyway; her daughter is a doctor in another city. An energetic man who photographs weddings on the weekends and has advised me on different types of drones (don’t tell him, but I’m not interested in buying one). A younger woman who always has a book with her and is partial to Gabriel García Márquez. 

As a native Texan and a Spanish minor at UT Austin, my command of the language used to be decent, but I let it fall by the wayside when I moved to Seattle for residency and found I didn’t need it. The demographics of Washington state are like another country when compared to Texas; Vietnamese and Tigrinya would have been more useful. I wasn’t sure where I’d end up after residency. When I opted to move back to Dallas and take my current job, I started Spanish lessons again and forced myself to watch Netflix movies dubbed into Spanish. I had only made a dent in recapping what I’d already learned when I lost motivation; I was spoiled by the translators and had other interests that pulled me away.

I ended up doing a lot of the Spanish speaking myself, in a form of hybrid communication. I like to think it was more “Span” than “glish”; undoubtedly it fell somewhere on the spectrum.

I can understand Spanish pretty well and ask all the questions I might need to know the answers to—¿Esta tosiendo? ¿Ha tenido fiebre? ¿Con quién vive?—but can’t always form coherent answers to a patient’s questions, and certainly not in a nuanced way. I don’t feel this limitation with a translator by my side, keeping me company on rounds. Often they’ll have already seen a patient I am meeting for the first time and will be able to add information: “Doctor, this patient was much more confused yesterday. She’s looking better today.” Or, “I saw him when he was in the emergency department last week. His daughter was here and has his medications with her.” 

Of course, the safety of patients and staff members comes first. With the infectiousness of COVID, which spreads like wildfire unless it’s handled as such, only essential medical staff can enter the highly regulated Tactical Care Unit, the hospital wards where Parkland houses coronavirus patients. Instead, I call a language line on my phone or over an iPad that gives me 43 dialect options. (I know because I’ve listened to all 43 options before, only to find after the final option of Taishanese that the language I needed—Hakha Chin—wasn’t on the list, forcing me to push 0 for “all other languages” in the end.) For Spanish, I just press 1. But in the Tactical Care Unit, my phone has to be sealed in a plastic bag. The sound quality of using speaker capability on an iPhone through a bag—not to mention while speaking through an N95 mask and face shield—is terrible. Phone interpreters kept telling me, “Doctor, I am getting a strange echo.” I know! What do you want me to do about it? 

The iPad stays in the Tactical Care Unit and doesn’t have to be sealed in a bag, but it reaches only a certain volume and must be heard over high rates of oxygen being pumped into patients’ nostrils and mouths, creating a baseline of white noise that mutes patients’ voices and vies with my own words for the attention of their ears. There’s yet another impediment: patients with coronavirus have lungs made soggy with inflammation, rendering them capable of speaking only a few consecutive words. I ended up doing a lot of the Spanish speaking myself, in a form of hybrid communication. I like to think it was more “Span” than “glish”; undoubtedly it fell somewhere on the spectrum.

Those patients who were the hardest to communicate with were also the sickest. The ones who all ended up with tubes down their throats, on ventilators, who might never have a conversation again. The one who asked me about her sister, who also had COVID and was critically ill in the ICU, “¿No va a recuperar?” I frantically tried to remember if using the subjunctive tense makes an expressed possibility seem very likely or very unlikely—an idiosyncrasy of the Spanish language that doesn’t translate to English.

COVID isolation illustrationI did my best to field questions about el virus, one of numerous cognates between Spanish and English that hint at our common roots and how much we’ve borrowed from each other. As with my patient’s query about her sister, it’s tough to answer questions, even in your native language, when you aren’t sure of the answer. While data about COVID have come at us like water from a fire hydrant, much of it isn’t definitive, or, worse, it’s conflicting. I lingered at my patients’ bedsides, hoping that more time there would somehow lessen the divide or at least communicate that I cared. It’s the same thing I do when I tell patients, those with metastatic cancer or incurable infections, that I don’t have any treatments left to offer them.

While most Americans are stuck at home, feeling isolated from our friends and regular social outlets, we have our health and our families. We live in a world that we understand and that understands us. But my patients don’t speak the language and are cut off from their loved ones. Only those who are imminently dying can have family members by their sides. The children, grandchildren, nieces, and nephews who would typically drop other duties and appear to help relatives navigate the hospital are unavoidably absent. Nurses set up Zoom calls with families, or I FaceTime a spouse or child from the patient’s room so they can at least see each other’s faces, if not hear all that well. Parkland has created entire teams of staff members pulled from other duties whose main job now is to call and update families. But these sickest patients, trapped in an unfamiliar environment, ailing from a virus about which we are still amassing information, are truly isolated. 

When I was struggling to communicate with an elderly woman for reasons more related to age and cantankerousness than language, her roommate (each COVID room has two patients) called the patient’s daughter, whose number she’d saved in her phone as vecina cama (“neighbor bed”), and put her on speaker. Her phone, of course, had the superior sound quality of not being in a bag. She’d been talking with the daughter regularly and encouraging the older woman to eat and participate in her care, serving as a surrogate family member. I greeted the daughter and smiled at the roommate in appreciation only to realize she couldn’t see my mouth, then thanked her profusely in my Spanglish. 

I miss having family members around. On the other hand, their presence is a sobering sign of a poor outcome. One evening, as I lined up to reenter the Tactical Care Unit to check on a few patients before heading home, I fell into a bottleneck of employees behind a young woman. She was a visitor, out of place in street clothes, likely entering to see a parent for the last time. Crossing the threshold into the TCU involves signing in, having your temperature taken, entering an antechamber where surgical techs guide you in donning shoe covers, a hair cover, a plastic gown, two layers of gloves, an N95, and a face shield. We were waiting for the techs to find someone bilingual who could instruct the woman in Spanish on this cloaking process that was alien to her but had become part of a new normal for us. We certainly try: the techs, the nurses, the social workers, the physicians, the fellow patients. But unless a coronavirus patient is drawing her last breaths, the sun rises and sets on her alone.

I greeted the daughter and smiled at the roommate in appreciation only to realize she couldn’t see my mouth, then thanked her profusely in my Spanglish.

My experience that week was common. But a number of Parkland’s clinicians are, in fact, fluent in Spanish. We also deal with a long list of other languages, even more than the 43 options presented on the translator line. Early in the pandemic, one of my colleagues was caring for an Arabic-speaking patient in his 80s who was hard of hearing. Communicating with a phone interpreter was impossible. She tried to arrange an exception for the patient’s son to come into the hospital, but before that could happen, the son rapidly manifested severe COVID symptoms and ended up on a ventilator in the ICU. She couldn’t tell the patient this, nor counsel him on what might happen if he became similarly ill. My colleague went from office to office in the hospital, searching for a clinician, anyone, who could speak Arabic and enter the Tactical Care Unit to communicate with her patient.

That week for me is over. I will “do COVID” again, but now that I’m back to my routine, I’m less bogged down with personal protective equipment and again have access to my translators. I feel a reinvigorated sense of novelty and appreciation when I arrive at a patient room to find the man or woman in the royal purple polo waiting outside the door, as I requested, there to bridge the gap between me and my patients. Meanwhile, ironically, I’m taking a course aptly titled “Translation” in my time outside the hospital. My fellow students and I use glossaries and Google Translate to transform poems from languages we don’t know into English. We then read each other’s products, all of which are different, with varying intonations, phrasings, and, ultimately, meanings. 

COVID isolation illustrationIn one assignment, we took an English poem that had been translated into Polish and performed “reverse translation” back into English. My English version of a stanza was “As children, we knew nothing but what we needed to know. To us, words traveled on wires, stuck in shiny drops left by the recent rain.” The original went “We were small and thought we knew nothing worth knowing. We thought words traveled the wires in the shiny pouches of raindrops.” Recognizable, but not the same. I’m left wondering what is lost, or distorted, in all areas of translation.

While I don’t expect myself to learn Arabic, I’m dealing with the guilt of not having stuck with my Spanish lessons. I’m also left questioning why I was not one of the first to volunteer to care for patients with coronavirus full time. The answer I come up with is a sense of fear. Fear not of the virus itself but of the medical limitations in being able to fight something still mysterious and my own personal limitations in being able to clear new hurdles in my path.

In my time at Parkland, I’ve honed my use of facial expression and touch to try to overcome barriers in communication. While N95 masks and full gowns are required only for COVID patients, surgical masks and face shields are now required for any patient contact. Only my eyes peek out from behind my mask, and I’m cautioned to stay 6 feet away as much as possible, even with my personal protective equipment. A smile, a touch on the arm—I’ve lost these basic human ways of connecting. Sometimes my face shield fogs up, and even my eyes are seen through a haze. All I have left are my words, projected through my mask and face shield, in a language that is not my own. 

¿Me escucha?


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