There is a man living in New York City who once suffered a traumatic brain injury and is now frequently brought into our ED by EMS with a chief complaint of “seizure.” Often providers order labs, imaging and medications, prescriptions he doesn’t fill and make clinic appointments he never attends. He appears disheveled so many assume he is addicted to alcohol and has seizures due to withdrawal.
“Seizure” is the one of the few English words this man knows. He is Polish, as am I, and in speaking with him in Polish, I’ve come to understand the circumstances that have rendered him one of our “frequent fliers.” He is street homeless and often sleeps on sidewalks or park benches. Concerned passersby call EMS to help, but they cannot understand him so he says some of the only English he knows – “seizure” – and they bring him to our ED where miscommunication leads to the usual algorithm.
Although this man does indeed have a seizure history from his TBI, I haven’t once seen him seizing or post-ictal. He admitted heavy alcohol use decades ago but denies drinking now. When asked in Polish, he usually says he doesn’t know why EMS brought him in but that he’s cold or tired or hungry. I give him a sandwich and discharge him to rest in the hospital lobby where no one will kick him out into the snow.
When others have tried assessing him with the help of an interpreter, his cognitive deficits from the TBI limit his cooperation and the endeavor is largely futile. In communicating with him in his primary language, I’ve been able to spare him unnecessary radiation, save our team time, and foster mutual respect in a situation vulnerable to judgment and stereotyping.
My parents immigrated to the United States from Poland in the 1980s and built an incredible life for my two brothers and me. We all grew up speaking Polish at home and English at school. Although as a child I rued going to Polish school every Saturday (meaning fewer sleepovers and limitations on my participation in soccer leagues), I am now deeply grateful to my parents for my ability to speak, read, and write in Polish. Still, growing up on Long Island, I spoke primarily English and therefore my Polish fluency is curtailed by a youthful accent and high school level vocabulary. I say this not to be self-deprecating but to be realistic about my limitations and demonstrate that I would certainly not pass for a medical interpreter. Nonetheless, my language skills have been instrumental in connecting with patients and have sometimes dramatically changed the course of patients’ care.
“POSSIBLE STROKE TO TEAM 3!”
An elderly woman was brought in by her family for sudden onset weakness. The usual rush to do a thorough neurological exam and get the patient to the scanner was more chaotic than usual and one glance at her name in the chart made it clear she was Polish. Though I hadn’t initially been the primary provider, I was the only person in the room capable of performing her stroke assessment.
My exam identified multiple large neurologic deficits, including aphasia, consistent with a massive stroke. There was no hemorrhage on head CT and her symptoms had been present less than an hour. She was taken straight from the scanner to the Neuro-Interventional Radiology suite where a successful thrombectomy was performed. She walked out of the hospital without deficits.
Though I know my Polish is imperfect, and I vividly recall medical school lectures warning us to always use an interpreter, the intensity and speed with which we must work in the Emergency Department makes this particularly challenging. Every EM physician has seen the stroke assessment of a non-English speaker occur with miming, via a family member, or by four people simultaneously shouting at an interpreter phone. My ability to speak with this woman in her primary language not only led to a more rapid and accurate assessment, but also allowed me to identify subtle abnormalities in her speech and language that may have otherwise been missed.
A young woman came into our Emergency Department for evaluation of an arm injury. She said she fell while walking down the stairs. Her imaging was negative but her exam revealed diffuse ecchymoses in various stages of healing. The woman spoke some English, more than enough to get by for a complaint of arm pain, but her primary language was Polish. Despite respectful, non-judgmental inquiry by her providers with the help of a telephone interpreter, she denied intimate partner violence.
I stopped by to say hello, as I do with all the Polish patients in the department. After introducing myself, we chatted for a few minutes about where she was from in Poland, and I told her about spending my childhood summers on my grandparents’ farm. When I expressed my concern for her injuries, she opened up and admitted she was harmed by someone she knew. She felt ashamed and didn’t want anyone to know. She promised she had a safe place to go and had formulated a plan for getting out. She refused to press charges or speak to social work.
I do not know if she returned to an unsafe situation. I do not know if she is alive and well or injured or deceased. This weighs on me but I take comfort in knowing that through our common language, a connection was formed in which she could tell her truth and be heard.
Connection, rather than tests or pharmaceuticals, is sometimes the most therapeutic thing we can offer someone in the Emergency Department. In our fast-paced, loud, microcosm of the world, we have the privilege of treating the underserved, the dying, and the frightened. Yet by virtue of sheer numbers, an end-sum game of limited time and resources, our evaluations are inherently limited. Subtleties are missed, errors are made, and occasionally people suffer as a result. Perhaps the best defense we have against this is the therapeutic relationship we create with our patients, allowing us to get to the heart of the problem more efficiently.
In the most diverse city in the world, speaking Polish has been the decisive factor in my forming that relationship with multiple patients. I have found that by communicating with the patient in their primary language, as the physician and not through an interpreter, I am better equipped to recognize subtle differences in presentation that guide nuanced management decisions – when to do less, when to do more, and how to identify the fundamental issue that brought that person to our ED that day.
Although not every physician can speak every language, we should encourage diversity in our providers that mirrors the diversity in our communities and utilize our cultural commonalities for the good of our patients. Speaking the language of the patient makes a frightening, life-threatening situation a little less foreign, and removing that tension allows for clearer insight that could make all the difference in our patients’ lives. Despite my youthful accent and vocabulary, I know that I have impacted lives because of my Polish language skills, and every day I work on my Spanish for that same reason. I don’t deny the wisdom of medical schools in teaching us to be humble about our fluency and cognizant of cultural differences, but perhaps the benefits outweigh the risks in our EM environment. Regardless, I cannot thank my parents enough for encouraging me to learn the language.