The Unspoken Damage of COVID-19 on Spanish-Speaking Patients

The Unspoken Damage of COVID-19 on Spanish-Speaking Patients

The COVID-19 pandemic has uncovered some ugly truths about the American healthcare system. One of the ugliest is discrimination against non-English-speaking patients. This form of discrimination particularly affects native Spanish-speaking only patients (defined in this article as “Spanish-speaking patients), who comprise not only a large proportion of America’s hospital patronage but also a majority of those suffering from COVID-19.

In May 2020, as part of my Emergency Medicine residency training, I worked at a small community hospital in northern Virginia, located in an agricultural area with a large number of Central American and Mexican migrant workers. The first few days of the rotation were relatively unremarkable until the COVID-19 cases began to pour in. Most of those suffering from severe COVID-19 were Spanish-speaking patients employed at a local plant nursery where an outbreak was occurring.

I intubated a COVID-19 patient almost every day I worked there. I speak Spanish fluently, and since I was able to communicate with Spanish-speaking patients and their families, I was able to obtain consent for the procedure. I will never forget one patient who had tears rolling down his face shortly after intubation as we titrated his post-intubation sedation medications. I spoke with his son over the phone, in Spanish, who thanked me profusely and cried, worried he would never see his father alive again. He asked if he could visit his father in the hospital. He cried more when I explained the no visitor policy for hospitalized COVID-19 patients. He still thanked me.

The ER staff also thanked me, because until I arrived, few in-person Spanish interpreters or fluent Spanish-speaking providers worked there. Therefore Spanish-speaking patients consented to intubations using a phone-based interpretation service. Though The Joint Commission states that telephone or video interpretation is sufficient to obtain informed consent (especially during the COVID-19 pandemic), in-person interpretation has proved superior. Unfortunately, at this small hospital, out of necessity and due to inundation by COVID-19 victims, Spanish-speaking patients had occasionally been intubated without true informed consent. For example, I remember a case when the overwhelmed nursing staff struggled to connect to and understand the phone-based interpreter while donning PPE and equipping a Spanish-speaking patient’s room for emergent intubation, only to be followed shortly thereafter by another critical COVID-19 patient.

Despite the large number of Spanish-speaking patients receiving care in the United States, a 2016 survey of 4,586 American hospitals showed that only 56 percent offered some sort of linguistic and translation services. As a former volunteer Spanish interpreter for a university hospital, the cost is cited as the primary reason, among many. Discrimination against undocumented people and xenophobia are unstated reasons. I remember distinctly a Grand Rounds presentation about native Spanish-speaking patients in hospitals and how a Latinx pediatrician emotionally expressed how often she witnessed Spanish-speaking families receive worse care than their English-speaking counterparts. Indeed, inadequate or inaccurate interpretation has resulted in serious legal, financial, and patient safety repercussions for hospitals.

In June, I worked in the COVID-19 ICU at my residency program’s hospital. Most of the COVID-19 ICU patients had been transferred from the same small hospital where I worked the previous May. After rounds, most of my afternoon was spent contacting Spanish-speaking family members and updating them on their loved one’s condition. It was heartbreaking to tell these families that they could not visit their loved ones in the hospital. Undoubtedly, the family is incredibly important to all cultures, and particularly to central and Mexican-Americans. Sadly, these strong family ties underscore an important reason Latinx people have been disproportionately affected by COVID-19: many live in large, multigenerational family homes, accelerating virus exposure and transmission. Furthermore, many are undocumented and work under substandard conditions, with few or no COVID-19 precautions. They may also be underinsured or have no insurance or benefits like sick leave, further fueling the virus’ devastation.

When you pull the bandage off a gangrenous wound to expose the decaying flesh below, you have two options: put the bandage back on and let someone else deal with it, or clean the wound and treat it so it can heal. The COVID-19 pandemic has pulled the bandage off and exposed certain disgusting realities of our health care system – how can we as Emergency Physicians heal this wound?

We must recognize that hospital under-investment in adequate Spanish interpreters is a form of racism. Medical Spanish should be required curriculum for medical students and residents. The knowledge of basic conversational Spanish goes a long way when communicating with patients and their families. Medical Spanish is not difficult, and there are enough cognates and Latin derivatives that most people, with minimal practice, can get through history and physical in Spanish. Most importantly, hospitals should invest in full-time in-person Spanish interpreters, at the very least for the Emergency Department.

The COVID-19 pandemic has ravaged our healthcare system in myriad ways. With destruction comes the opportunity to rebuild and improve. This is one area that needs it.

Cite this article as: Sarah Bridge, USA, "The Unspoken Damage of COVID-19 on Spanish-Speaking Patients," in International Emergency Medicine Education Project, January 11, 2021, https://iem-student.org/2021/01/11/covid-19-on-spanish-speaking-patients/, date accessed: April 21, 2021

Expert Opinion: Luis Vargas – ED Overcrowding

EMERGENCY DEPARTMENT OVERCROWDING

Dear students, emergency departments are suffering overcrowding since long time. There are various causes of this situation as well as solutions. It is better to know about ED overcrowding before your first shift. Dr. Luis Vargas from Colombia summarizes his lecture presented in 30th Emergency Medicine Congress of Mexican Society in Cancun.

ED Overcrowding - English

Manejo y consecuencias del sobrecupo en urgencias

Cite this article as: iEM Education Project Team, "Expert Opinion: Luis Vargas – ED Overcrowding," in International Emergency Medicine Education Project, March 29, 2019, https://iem-student.org/2019/03/29/expert-opinion-luis-vargas-ed-overcrowding/, date accessed: April 21, 2021

Against Medical Advice and Elopement

In certain circumstances, patients may request to leave prior to completion of their medical evaluation and treatment. In this situation, it is essential for the last health care professional caring for the patient to document clearly why the patient left and attested that the patient had the mental capacity to make such a decision at that time (Henry, 2013). While some electronic documentation systems have templates in place to assist with this documentation, Table 2 provides basic information for against medical advice (AMA) discharge documentation that can be used to create a uniform template (Henry, 2013; Siff, 2011; Levy, 2012; Devitt, 2000).

What to do?

Interventions in the ED Discharge Process

DomainIntervention
ContentStandardize approach
DeliveryVerbal instructions (language and culture appropriate)
Written instructions (literary levels)
Basic Instructions (including return precautions)
Media, visual cues or adjuncts
ComprehensionConfirm comprehension (teach-back method)
ImplementationResource connections (Rx, appointment, durable medical supplies, follow-up)
Medication review

An attempt should be made to provide the patient with appropriate discharge instructions, even if a complete diagnosis may not yet be determined. Include advice for the patient to follow up with his physician, strict return precautions, and concerning symptoms that should prompt the patient to seek further care. It should also be made clear that leaving against medical advice does not prevent the patient from returning to the emergency department for further evaluation if his symptoms worsen, or if he changes his mind. Despite a common notion to the contrary, simply leaving against medical advice does not automatically imply that physicians are immune to potential medical liability (Levy, 2012; Devitt, 2000). If a patient lacks decision-making capacity to be able to adequately understand the rationale and consequences of leaving AMA and his condition places him at risk for imminent harm, involuntary hospitalization is warranted. In unclear circumstances and if available, psychiatry can assist in determining capacity, especially in the case of patients with mental health conditions.

Elopement is a similar process where patients disappear during the care process. While it is difficult to provide discharge paperwork for these patients, documenting the actions taken to find the patient is essential (e.g., searching the ED, having security check the surrounding areas). In addition, attempt to reach the patient by phone to discuss his elopement and any additional care issues or concerns. Documentation of these attempts or any additional conversation is very important (Henry, 2013; Siff, 2011).

To Know More About It?

References

  • Brooten J, Nicks B. Discharge Communications. In: Cevik AA, Quek LS, Noureldin A, Cakal ED (eds) iEmergency Medicine for Medical Students and Interns – 2018. Retrieved February 27, 2019, from https://iem-student.org/discharge-communications/
  • Henry GL, Gupta G. (2013). Medical-Legal Issues in Emergency Medicine. In Adams (Ed.), Emergency Medicine Clinical Essentials, 2nd Ed; 1759-65. Philadelphia, PA: Elsevier.
  • Siff JE. (2011). Legal Issues in Emergency Medicine. In Tintinalli’s (Ed.), Emergency Medicine, 7th Ed; 2021-31. McGraw-Hill.
  • Levy F, Mareiniss DP, Lacovelli C. The Importance of a Proper Against-Medical-Advice (AMA) Discharge. How Signing Out AMA May Create Significant Liability Protection for Providers. J Emerg Med. 2012;43(3):516-520.
  • Devitt PJ, Devitt AC, Dewan M. An examination of whether discharging patients against medical advice protects physicians from malpractice charges. Psychiatr Serv. 2000;51:899-902.