Thursday, February 15, 2007

Ramp Rants - Communication

Good language skills are a must in New Orleans. Not only must you communicate with people of various language backgrounds, such as Spanish, Vietnamese and deaf people, but also with those who purportedly speak English, and they can be quite a challenge.

For example, in order to comprehend the many dialects of English in New Orleans, one must learn “Old Black Lady.” In this dialect, rarely is a straightforward answer to a question forthcoming. For instance, when showing up at a scene and asking the patient what emergency summoned us there, the response will often be something to the effect of “my arm” (or leg or toe or ear... you get the picture). That's it, just the answer “my arm.”

Working from there, one must try to delve into all the problems that could possibly go wrong with one's arm. So we ask “what's wrong with your arm?”

“It's wern me.”

Not much help, is it? First one must translate this cryptic message. I was a bit at a loss the first time I encountered this response. We had been called to a residence for an elderly female complaining of “a problem with her arm.” We arrived at the shotgun double, the patient was in the front room, sitting on the plastic-covered sofa. About a dozen family members were present including little kids, adults, and teenagers. I settled on the couch next to the patient and the family gathered around in a semicircle, like it was storytelling time. None had said a word to me; the only communication had been one or two teenage girls pointing at the old lady, presumably their grandmother or great-grandmother, indicating that this was my patient. The lady looked reasonably healthy, not in any apparent distress. I asked her what was wrong.

“It's wern me.”

“I'm sorry, what did you say?”

“My arm. It's wern me.”

To the family members nearby: “I'm sorry, did you understand what she said?”

At this point I got a look from all of them that seemed to say 'what's wrong with this stupid white boy? She's speaking to him perfectly clearly but he's asking us what she said!' After this brief deprecating stare, one of the disgusted family members piped up and said “She said it's her arm. It's worrying her.”

Hm. Well that wasn't much help either. Was she worried about her arm? Why would one be worried about their arm? Might she imagine it will detach itself and crawl off to find a better life elsewhere? Does the arm whisper worrisome thoughts to her that keep her up all night? I looked around at the family members who were staring at me as if I were a strange fish in an aquarium. I got the distinct impression that they expected me to immediately whip out some magic pill that would cure her worrisome arm once and for all, as if our five sentence conversation was all that anyone could possibly need to form a medical opinion and pick the right prescription for Worrisome Arm Disorder.

I would have to heighten their disgust for me by asking more questions. “Can you tell me what you mean by that? I'm not sure what you mean by 'your arm's worrying you.'”

At this point the old lady gave me a look as if to say 'how can you possibly not know what I'm talking about? I've been very clear as to my symptoms and you've even corroborated my story with my family. What further information could you need?'

She responded to my inquiry with further clarifying information. “It's my arm. It's been wern me.”

Ok, so asking the patient what's wrong wasn't going to work. I was going to have to change the exam from an essay-question test to a multiple-choice test. “All right ma'am, I understand it's your arm. Which one?”

“That one,” she responds without any indication or body language as to left or right. I began to suspect that she spent her life as a poker shark, since nothing in her demeanor was letting any information through to me.

I took a chance. Grasping her right hand and elbow, I asked, “This one?” Again she stared at me, letting her facial expression communicate clearly that she got the impression I was an idiotic quack.

“No, the other one,” she at last answered.

“And what's wrong with it? Does it hurt?”

“It's wern me.”

“I know, but I'm not sure what that means. Can you tell me if it hurts?”

“Yeah, it kind of hurts.”

Progress! I was pleased that I had at least found something to start with. I looked around at the family members who apparently couldn't believe that I had taken this long to understand.

I plodded on. “How long has it been hurting?”

At this point I encountered another communications impasse that is common in the field of New Orleans EMS - references to time. People's perception of time is a fascinating study in sociology, but it can be a pain in the ass when you're trying to figure out what's wrong with a patient. To illustrate, if I were asked the same question, 'how long has it been hurting?' I would likely give a time reference along the order of 'three hours' or 'since early this morning' or 'since 5:30.' Not so with most of the population EMS serves. Her reply was “it's been hurting.”

Back to the multiple-choice. “Yes, but how long? An hour? A day? A week? A month? Ten years?”

She narrowed it down. “It's been wern me for a while.”

AARGH! What the hell is 'a while'? I turned again to the family, who were still staring into my fishbowl. “How long has she been complaining about her arm worrying her?”

They looked at me, then to each other, then back at me, as if they were astounded that the fish had addressed them yet again, but the question was simply bizarre. I repeated, “how long has she been saying her arm hurts?”

“Since she got back from the doctor.”

Here was another time reference that had no meaning. “When did she get back from the doctor? An hour ago? A day ago?”

“Last week.”

Finally! Something to form a vague outline of what's going on and why I might be there at the house. Her left arm has been hurting for a week, and now there's a doctor involved. The plot thickens.

It was time for some empirical evidence. I lifted the patient's left arm to see her reaction, since I could tell that asking about the pain would be a fruitless endeavor. She grimaced as her arm went up. Ah hah! Pain with movement! At least that would likely indicate some sort of orthopedic involvement. But what? Arthritis? A fracture? Did she sleep on it wrong? Since she indicated another factor, her doctor's visit, I decided to focus on that. “Why did she go to the doctor?” I asked to anyone who might be willing to give me a coherent answer.

After a little more staring, someone offered “She went after she got in that car wreck.”

Bingo! “And what did the doctor say was wrong?” I knew I was pushing it, because I knew what the answer would be.

“They didn't tell her nothin'.” As expected, the standard reply. This highlighted another communication difficulty. In nearly every similar situation, when patients have previously been discharged from a doctor's office or a hospital, the patient will usually tell us that “they didn't tell us nothin'.” On the other hand, I have overheard and been directly involved with patient-doctor-nurse interactions and invariably have heard some reference to the patient's diagnosis and source of their troubles. 'You had a heart attack,' 'you have the flu,' 'you sprained your ankle,' 'your blood sugar was too low,' and so on are among the countless explanations given to patients by medical staff to explain their diagnoses. I am at a loss as why patients are unable or unwilling to incorporate this knowledge into their conscious mind, but now I was dealing with what would certainly be yet another example of this phenomenon.

If they were discharged from the hospital, they were no doubt given discharge instructions which should have their diagnosis on it. I gave it a shot. “Did they give you a paper when you left? Can I see it?”

“Yeah, awright,” One of the female family members replied with a sigh normally reserved for one who has just been tasked with the responsibility of moving a mountain from here to there using only a teaspoon. She brought out a sheaf of yellow papers, all discharge instructions from dozens of other doctor's visits. She located the right one and handed it to me. I read what the ER nurse had written on it: “Left arm contusion s/p MVA. Elevate arm, apply ice packs. Rx Vicodin.”

There it was. Left arm contusion (bruise) s/p (status post [after]) MVA (motor vehicle accident). Although it was somewhat ensconced in medical jargon, the diagnosis was written clearly on the yellow paper – she had a bruise on her arm from a car accident. It also indicated that she had been given a prescription for Vicodin and instruction to follow when she got home, namely to elevate her arm and apply ice packs.

“So she went to the doctor last week after her car wreck because her arm was hurting, right?” I asked the family.

“Yeah,” said the woman holding the wad of old discharge instructions. I reflected on the previous answer when they told me her arm was hurting since after leaving the doctor, subtly indicating that her pain was somehow the doctor's fault.

“And did you get the prescription filled?” I asked, knowing what the answer would be.


“And have you been keeping her arm elevated with ice packs like it's written right here?” knowing what the answer would be.

“Well, when she got home we put some ice on it, but it's still hurting her.”

“You have to keep putting ice on it, and you have to keep elevating it. And that prescription was for pain medicine, so you need to get it filled and take the medicine. It's no wonder she's still having pain.” I turned back to my patient. “You don't need to go back to the emergency room for this; you've already been there for this same thing. What you need to do is follow up with what they told you do to make your pain stop. Understand?”

“But my arm's wern me.”

I was at the verge of exasperation. As I got the woman to sign the refusal, I tried once again to encourage them to follow up with their instructions and fill their prescription, but I knew I was now suffering from a communications disorder, Talking To A Brick Wall Syndrome.

The art of communication in EMS doesn't just apply to talking to patients. EMS has a whole Communications Center whose sole role, it sometimes seems, is to inhibit expeditious communications between dispatch and the street units. There is a bewildering array of police signals and “10-codes” that takes months to get used to. Nowhere else but in emergency services can you have a conversation consisting of nearly nothing but numbers. To wit:

Dispatch: “6201, take in 1604 Fourth, on a 34 secondary to a 103-F. Item is 682, 1322.”

Unit: “10-4. 980 from Charity. Gimme a little delay, my partner's 10-42.”

Dispatch: “10-4, 1323.”

The translation: Unit number 6201 is being sent to respond to a call at 1604 Fourth Street, where there is someone who's been beaten up (Signal 34) following a fight (Signal 103-F). The number used to keep track of the call is 682, and they were dispatched at 1:22 PM (1322 in military time).

The unit acknowledges (10-4). The beginning mileage on the odometer is 980 (to keep track of distance and response times) and they are leaving Charity Hospital. They also let dispatch know that there will be a slight delay in responding, because one of the medics is going to the bathroom (10-42).

Dispatch acknowledges the message (10-4) and gives them the updated time, now 1:23 PM (1323).

Once you get used to it, the numeric vocabulary is very efficient. In fact I often find myself away from work speaking to others using 10-codes such as 10-4, or 10-9 (could you repeat that?) or 10-20 (where are you?).

On the other hand, when we are sent to calls, no matter how efficient the numeric conversation might be, there always seems to be some sort of miscommunication. What dispatch tells us must generally be taken with a grain of salt. For instance, on several occasions I've been dispatched to a Signal 24 (medical emergency) in which the patient was a little old person feeling weak according to dispatch. When we actually arrived on scene, we entered the house only to find the little old person a little beyond generalized weakness and actually in cardiac arrest, or to put it in layman's terms, dead. That's pretty weak!

It's not always dispatch's fault, though. I've worked in communications many times and the majority of people who dial 911 have no idea about what's wrong with the patient, who the patient is, or even where they're calling from.

Many 911 calls go something like this:

Dispatcher: “Emergency medical services, do you have an emergency?”

Caller: “Yeah, uh, she be sick.”

Dispatcher: “What do you mean?

Caller: “She be sick, man. Just send us a ambalamps.”

Dispatcher: “Sir, can be a little more specific? What do you mean by 'sick'?”

Caller: “Dammit man! She be sick! What part of sick you don't unnerstand?”

Dispatcher: “Well, is she having pain, is she vomiting, is she having a seizure, any trouble breathing, is she in labor, or what? I just need to know what to tell the ambulance crew.”

Caller: “Yeah, she's havin all that!”

Dispatcher: Ok, lemme get this straight. She's in pain, vomiting, having a seizure, short of breath and in labor all at the same time? How old is she?”

Caller: “Yeah, all that. Hell I don't how old she is!”

Dispatcher: “Is this your family member?”

Caller: “Yeah, it's my mother, I guess she's like 89 or something.”

Dispatcher: “Ok, so your 89 year old mother is having labor pains on top of everything else. Right. What's your address?”

Caller: “I stay by my girlfriend's house on Claiborne.”

Dispatcher: “No, I mean where is the patient? I need to know where to send the ambulance.”

Caller: “Aw, hell, I don't know the damn address! Just send us a ambalamps!”

Dispatcher: “You don't know your own mother's address?”

Caller: “What the hell, man? Can't you just send us a ambalamps”

Dispatcher: “Sir, I'd be happy to, but exactly where should I send it?

At this point, the dispatcher might be able to look at the E911 display, which shows the address and phone number of the caller. However, often a caller will be using a pay phone some distance from where the ambulance is actually needed, or they may be on a cell phone, in which case the display gives the address of the cell tower. On occasion, 911 callers have dialed EMS from an entirely different state, requesting an ambulance for a family member back home in New Orleans. The most distant caller I ever spoke with was calling from Poland for his elderly father who lived uptown and wasn't answering his phone. Most commonly, the callers simply don't know their own address. Miraculously, though, they can figure out their address for their welfare application in order to have their government checks sent there. This is sometimes the only means of determining where the ambulance is needed.

Dispatcher: “Sir, can you tell me where her welfare checks are sent?”

Caller: “Oh yeah, that's 1301 Simon Bolivar, apartment 733.”

Dispatcher: “And is that where she is now?”

Caller: [light dawning] “Yeah, send 'em to 1301 Simon Bolivar in apartment 733.”

Dispatcher: “All right, we'll send them there.”

When the ambulance actually arrives on scene, rarely is the complaint specified really what's going on. Dispatch can listen to all the radio frequencies used in the city, so on a call like the one above, the dispatcher will often listen to the crew's report on the medical control channel, just to find out what's actually happening with the patient. In the above case, the report described an 80 (not 89) year old female who had been complaining about a dry cough for a couple of days. No pain, no seizures, no shortness of breath, no vomiting, and definitely no labor pains.

Many have been the times when I was sent to a shooting only to find out the patient was actually a little old lady complaining of weakness, that the person complaining of chest pains had actually been shot in the chest, that the motor vehicle accident was a drunk passed out on the side of the road, and that the 19 year old female with a vaginal bleed had actually just given birth to her fourth baby.

Further, the simple vocabulary of the populace is a factor to be reckoned with. It takes a bit of experience to figure out exactly what may be wrong with a patient. For instance, when asking a patient's medical history on has to extrapolate the vernacular into medical jargon. To wit: “Yeah, I gots da roaches in da liver,” translates to 'I have a medical history of cirrhosis of the liver.' “Smilin' mighty Jesuses” is actually 'spinal menigitis.” “Peanut butter balls” is phenobarbital.” “Fireballs in the Eucharist” translates to 'fibroids of the uterus.' I'm coughing up flegum” means “I'm coughing up phlegm.”

During one call, my partner Susan and I encountered a young mother whose son had a fever. She explained that she had rubbed him down with “akarol.”

“I beg your pardon?” I asked.

“He felt real hot so we rubbed him with akarol.”

She handed me the bottle. I read the label. “isopropyl alcohol” it read. “So you rubbed him down with ALCOHOL?” I inquired.

“Yeah, with alcohol.” came the answer I could understand.

At this point, the friend who was standing in the room chimed in. She said, “AKAROL! You rubbed him with AKAROL!”

“Yeah, I rubbed him down with akarol.” the girl replied.

“OK. I think I have the picture.” I responded.

Boy, did I have the picture!

Like I said, we need to take communications with a grain of salt, and a rather large grain at that.


index.php said...

Thanks for takin' me home. I can't decide if this post made me terribly homesick, or thankful I live somewhere where the worst butchering of the language is to say "aboot" instead of "about."

Fantastic stuff.

nickopotamus said...

Sounds like working in the Fens at the end of the train line... :S

The Happy Medic said...

Saw you on the Handover, glad I did. Great stories and well written Chapters to catch up on.


Ckemtp said...

Saw you on the handover, became a regular reader, put you on the blogroll.

Ahh, I miss New Orleans. I get to spend a lot of time down there with various work type things, but after work sure was fun. Once tried to get a part-time job with NOEMS... until I got transferred right before I signed the line.

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