The Wrong Solution

Contributed by readers/Edited by Sheldon Jacobson, MD, FACP, FACEP

CHEST PAINS AND SECOND LANGUAGES

One busy afternoon in the emergency department, a bright and spunky resident presented a new case to me. “I have an elderly woman with chest pain,” he recited, adding that the patient’s history was difficult to obtain because she spoke only Hungarian. “Her physical examination is unremarkable, but she has diffuse ST- and T-wave changes on her ECG and I feel she has to be admitted as an acute cardiac syndrome,” he opined.

I went to examine the patient and found that she was uncomfortable and was pointing to her chest and neck. The language barrier was a major obstacle to communication. I decided to admit her just to be safe and that the differential diagnosis would have to be completed upstairs.

Just as I was leaving the bedside, the patient’s daughter arrived. The daughter was a professor of English at a nearby college and she was able to obtain a complete history for me. She relayed that her mother had been suffering from severe muscle pains in her neck, chest, and hips for two weeks. The patient denied most of the symptoms of ischemic heart disease. She also denied headaches or changes in visual acuity.

The daughter left to pick up her son at school, saying she would return as soon as possible. The resident had no knowledge of her visit.

I went back to the resident and told him that I thought the patient had polymyalgia rheumatica. I requested that he add an erythrocyte sedimentation rate (ESR) to the other lab tests he was ordering. He looked at me quizzically and rolled his eyes but ordered the additional test.

When the ESR came back at 90 mm/h, my resident was overwhelmed by my clinical acumen. He became so compliant and responsive to my mentoring that I felt guilty about never having mentioned that I had obtained the history through the patient’s daughter.  When I told him how I had made the diagnosis, he seemed relieved and reverted to his usually spunky and irreverent personality.

The patient was started on low-dose prednisone and a follow-up was arranged for her in the geriatric clinic.

DISCUSSION

Polymyalgia rheumatica is a poorly understood syndrome that presents with mild to severe pain and tenderness in the musculature of the shoulders and pelvis. Potentially debilitating on its own, it has an association with temporal or giant cell arteritis, a disease of the elderly that can quickly cause blindness due to retinal ischemia because it affects the ophthalmic arteries. Patients with polymyalgia rheumatica should be asked about recent onset of headaches, jaw claudication, chest discomfort, and spiking fevers. On physical examination, the temporal arteries should be evaluated for tenderness, inflammation, and thickening.

This case is yet another example of how precarious the diagnostic process can be when the patient does not speak the physician’s language. In retrospect, it was clear that the resident had been correct in assuming the worst and wanting to protect the patient, himself, and the institution by having her admitted.

There are a number of medical translation services available. Each has its own intrinsic advantages and disadvantages and they all double or triple the time it takes to get the information. Some centers have certified medical translators on staff, but I doubt that many of them are fluent in Hungarian. A knowledgeable bilingual family member who is on hand to provide translation is often the best available resource. However, these individuals are not medical professionals and their communications may be erroneous or biased.

Sometimes the situation demands a creative solution, and so it is with several of my emergency medicine colleagues who work in small, isolated facilities. When their patient is a non-English-speaking Asian, they tell me, they have been known to call on the translation skills of the employees at their local Chinese or Japanese restaurants.