HAM! BUR! GER!

How often do you run a call that involves a patient (or family or bystanders) with a grasp of the English language that could charitably be described as tenuous?

It happens to me all the time. America is a nation of immigrants. In addition, plenty of foreign visitors come to the country for both business and pleasure. It is not uncommon at all to have language barriers on a call. There are ways around language difficulties. There are phone-based interpreter services. You may speak the patient’s native language. There may be other people on scene that can provide translation. 

In my opinion, I don’t like to use non-professional translators. The family member (or worse, bystander) who is doing the translating may not need to hear about the patient’s medical problem. Medical problems are private in many cases. So I prefer the professional anonymity that “language line” services provide. Hopefully your agency offers something like that. 

In a lot of cases, though, the patient speaks limited English and basic communication can occur between the provider and patient directly. I have seen a lot of partners make this harder than it needs to be. I can pretty much guarantee that I have made it harder than it needs to be in my past. So here are some tips and lessons to facilitate communication with a person for whom English is a challenge.

Sometimes it is hard for me to find a picture that makes sense for the article.  So enjoy this one.
Source

1. Don’t shout. This is one of my pet peeves. They aren’t deaf; they just don’t speak English. I grew up in Europe and so I think I notice the “ugly American” getting louder and louder: “Hamburger! HAMBURGER! HAM! BUR! GER!”  Volume doesn’t help. Just speak in your normal, conversational tone.

2. Speak slowly, one word at a time. This is different from speaking words slowly. Speak. Each. Word. Separately. In. The. Sentence. This gives the other person a bit of time to recognize each word. Don’t change your word cadence: Doooonnn’tttt sllloooow doooowwwwwn eaaaaaccchhh wooorrrrddd. On a related note, separate your words instead of running them together. “Did you…” works much better than “Didja…” The problem is that most of us don’t recognize when we are throwing didja’s around.

3. Don’t use baby talk, slang, or incorrect English. Contractions are more difficult to understand than separate words: cannot is better than can’t. Keep your words and sentences as simple as possible. Medical terms probably weren’t covered in the entry-level English class the person you are talking to took, so simplify your words there, as well.

4. Speak about one thing at a time. Ask only one question at a time. It is amazing to me how common it is to have a partner shotgun two or three questions, or two versions of related questions: “How does your chest feel? Did you hurt it in the crash?” Blasting a patient with two questions is more confusing. (And it is usually done in a louder tone than necessary. HAMBURGER!) Ask one question and give the person time to absorb it. They also need more time to formulate their answer – they are translating both the question and the answer in their head. So ask your question and stop talking.

5. Um, this one is, like, sort of tough for me unless I think about it and all. Don’t use habitual fillers. When someone is first learning another language, sounds like ‘um’ sound like words. Filler words (like, totally, and all, and so on) complicate a sentence, as well. Keep your sentences as simple as possible.

6. Body language goes a long way. When your words carry less impact, other forms of communication have to carry more. So use your hands to point to things. Point to your head when you ask: “Does your head hurt?” Also, smile more. You can’t easily use your words to say that you are there to help. You have to show that you are there to help in other ways. So make sure you are giving off an open, friendly vibe.

7. If you have to repeat a question, repeat it the same way you asked it the first time. Don’t change your wording. 

8. Keep in mind that cultural differences exist. Different cultures have different expectations of personal space, for example. People from face-based cultures may not admit they don't understand you. Some people may be extremely uncomfortable at being touched, so you will need to ask first. The list of potential cultural differences is too long to get into here, so just do your best.

Next time you see your partner shouting two questions in a row, you can wince like I do when I see that. Just remember that your partner probably doesn’t even know that he or she is doing it. I didn’t until someone gently told me…

The Secondary is Primary

I was working with a trainee and we were sent to an assault at a discount shoe store. Dispatch told us that the manager had been beat up during a robbery, and the cops were already on scene. I was deeply hoping that the shoe store manager/patient looked like Al Bundy. I was a little disappointed when he didn't. 

Anyway, the story we were told is that a guy tried to take money from the cash register. Our intrepid patient tried to stop him, a struggle ensued, and the patient wound up with his head under the robber’s arm. Picture two men facing each other, one bends over so his head is next to #2’s ribs, and #2 wraps his arm around #1’s neck. It is the start of a jiu-jitsu guillotine choke, if that makes sense to you. From that position, the robber punched our guy in the back several times and ran away.

The shoe store manager neither had a sparkly leotard nor a mullet, but you get the idea.

By https://www.flickr.com/photos/10542402@N06/ [CC BY-SA 2.0], via Wikimedia Commons

The manager denied being hurt. He said his nose was a little sore, but not a big deal. It was the police that requested our company, based on a fight having occurred. The patient wasn’t knocked to the ground, not choked to airway closure, and not solidly struck. The trainee checked his nose, found it to be sturdy and minimally tender, not bleeding, and otherwise generally atraumatic. 

The trainee took a blood pressure and began to walk away, as though he was about to go in service. That action made me rather angry. One of the first things I tell trainees (and paramedic students, as well) is to perform a full head-to-toe secondary exam on every patient. My trainee didn’t touch the patient, outside of his nose. The proto-medic didn’t have all the information needed to make a decision, much less terminate the call.

I reminded the trainee about my desire to see a complete secondary exam on every patient. I think I was even sort-of polite and almost not hostile at all when I did so. 

The trainee returned to the patient with a sheepish expression on his face. He checked the patient’s head and face and lifted the manager’s shirt. Next, he asked the patient to spin around so he could see his back.

That was when he found twenty-two stab wounds in the patient’s back.

Apparently the punches to the back weren’t punches. Or they were punches, but there was a knife clenched in the fist as well. The story worked out that after the fight, the patient’s shirt was torn. So he changed it while he was waiting on the cops. That was why there were no bloody holes in the shirt. 

I can’t emphasize the importance of a secondary exam enough to a trainee. Everyone thinks they can cheat on a physical exam. But to me, it is all we have for physical information gathering. A hospital can shoot an x-ray, perform an ultrasound, draw labs, and even find a room quiet enough to listen to heart tones. We don’t have any of that at our disposal. All we have is the ability to perform a great head-to-toe exam. 

I think that two problems cause this. First, newer paramedics are embarrassed about the full exam. They think patients will call them out for checking their head, when we were called for an ankle problem. They think people don’t want to be groped by medics. Here is the physical exam pro-tip: People don’t notice. People even subconsciously expect an examination. It feels medical. It makes sense to patients and bystanders. It is not off-putting to patients in the least. That is especially true when you tell them that you’re going to check them out completely, starting with their head. In short, patients neither mind nor notice. Grope away.

Second, I think modern schools don’t teach primary-secondary exams anymore. I’m apparently a dinosaur for even referring to a physical exam as a “secondary exam.” Now EMTs are taught about Focused Assessments, Rapid Assessments, and Detailed Exams. At least one site says:

Many of your patients may not require a Detailed Physical Exam because it is either irrelevant or there is not enough time to complete it. This assessment will only be performed while enroute to the hospital or if there is time on-scene while waiting for an ambulance to arrive…

I strongly and emphatically disagree with that tripe. My blood pressure rises each time I read it, while editing this post. But it explains why many of my new paramedics and trainees think they can get away with half of the required information collection available to a medic.

It is amazing to me how often I find something during a physical exam that isn’t specifically related to the patient’s complaint. Other problems are found. Related issues are found. More of the story is found. I get repeated practice identifying normal breath sounds, pupillary responses, and other exam findings – to the point that abnormal alerts me on a subconscious level. I cannot understate the importance of secondary exams.

Exams are important enough that thick-ass books are written about how to perform exams. Clinicians have used physical exam to do astounding things.* And, again, it is about all we have in the prehospital setting. The only other viable way to gather information is via verbal history. 

Don’t give up half of your potential information.

Perform complete head-to-toe exams. Every patient, every time. I can’t get any more clear than that. Every patient, every time.

*Karl Frederik Wenckebach described the partial blockage of AV conduction that bears his name in 1899, based on physical exam findings and irregular pulse strength.  Willem Einthoven invented the string galvanometer that was used to create electrocardiograms in 1901.  Wenckebach described a Type I AV block before the ECG was invented!  Based on physical exam!

Titrate to Effect

A couple of shifts ago, my partner and I were assigned to a nonemergency fall. I was attending. We arrived to a well-kept little house on a nice little street. A man across the street from the call address stopped mowing his lawn and walked over to the ambulance when we pulled up. 

“They’re both deaf,” he said with a shrug. “She fell down and her husband asked me to call.” I nodded, smiled, and thanked him. In order for my dispatch to assign me to a fall victim without the use of firefighters, flashy lights, and loud sirens, the fall must be minor. I expected a lift assist, as a matter of fact. This guy's unperturbed demeanor solidified that notion in my mind.

The EMS gods have repeatedly tried to teach me that I can’t prejudge calls. After 20ish years in EMS, you think I would get this lesson. Nope.

Inside the house, I found an 80-something year old female who had fallen from a standing position to a carpeted floor. She had caught her foot on one of her dogs and it tripped her. She fell kind of across an ottoman and onto the carpet. She had an angulated distal tib-fib fracture. (Yeah. Paramedics shouldn’t diagnose. Whatever. I could see that this leg was broken.) The angle of the fracture was accompanied by a laceration, making this an open fracture, but the bone wasn’t sticking out.

You've heard of a Colles' Fracture, nursemaid fracture, and so on? This is called a "Janitor's Fracture." That's because you don't need medical school to read the x-ray. A janitor could walk by and say: "That's broken..."
Credit: By 2Lt Karl Wiest (https://www.dvidshub.net/image/246359) [Public domain], via Wikimedia Commons

She was a nice lady.  She was deaf, and couldn't/wouldn’t speak. (I found out later that some deaf people can vocalize, but are embarrassed by the “deaf voice” so they choose not to speak.) She also couldn’t lip read, so we communicated by writing notes on my notepad. Her husband was also deaf.  He could read lips, sign, and spoke. He spoke quite loudly. Like, at the top of his lungs.  Dude bellowed his answers like he was in the middle of an artillery barrage or something. It was endearing. I honestly liked both of them.

I performed a head-to-toe check of the female patient. The distal leg injury appeared to be her only problem. It wasn’t distracting her, so I was confident that nothing else was severely injured. Her vital signs were fine, as well. So my priority was extrication from the house and transport to the hospital. Extrication would go better if the nice deaf lady was premedicated, so I sent my partner to fetch the narcotics. I started an IV and her husband screamed a list of prescription medications at me while we waited. 

We dosed the patient with 100 micrograms of fentanyl and waited several minutes for the medication to take effect. When I saw her release a subtle little sigh and relax a bit, my partner and I straightened and splinted her leg with a SAM splint with kerlix. She maintained distal pulses after splinting. After that evolution was done, we gave her a minute to settle herself and then moved her to the pram.

In the ambulance, I could tell that my patient was still rather uncomfortable. I gave her a second hundred-microgram fentanyl dose. I spent several minutes getting everything set for the transport. I rechecked her vital signs, checked the distal circulation of her foot, called to set up the hospital, and generally made sure I wasn’t missing anything. I wrote her another note on my pad: Is your pain level tolerable or would you like more pain medicine to make you more comfortable? If she wanted more medication, I was prepared to switch to four-milligram doses of morphine. She took the note from my hand and held it in front of her, close to her face, so she could read it through her myopia and the vibrations of driving down the road.

And held it.

And held it.

I didn’t think it was that long of a note. I looked at her more closely to see what the hell was going on. Did I spell something wrong, or what?

She was asleep.

I smiled. Perfect. My written question was answered. Therapeutic dose achieved. As a matter of fact, I needed to monitor her more closely being that she was elderly and I had snowed her. I put on pulse oximetry and oxygen via nasal cannula. I made sure she was comfortable, but not overdosed. She woke easily to a light squeeze of her shoulder. She was exactly how I would want my mother or grandmother to be if they had fallen and gotten their foot to point the wrong direction, with the bone through the skin. So sleep away, nice lady. At the hospital, she woke to help move herself from the pram to the hospital bed and go through the ED staff introductions. Then she fell back to sleep. Awesome.

This is exactly the kind of call I am talking about when I say that the first rule of EMS is to help people; make someone’s situation a little better. Mission accomplished.