From the Wards
Leave a comment

Ustedes Son Muy Amables

I met Rosa on my first rotation. My clinical year began with overnight shifts on the OB/GYN service at an affiliate hospital. My second night was halfway over when, at two in the morning, Minnie and I were summoned to the emergency department. Minnie, the resident that I was paired with, relayed to me that our consult call was for a woman who was suffering moderate vaginal bleeding. Rosa was young, spoke only Spanish, and believed she was eight or ten weeks pregnant. She was “G3P1011”: she had one living child, but lost one in an abortion. As our feet echoed loudly through empty hospital corridors, Minnie asked if I could translate; though she knew “medical” Spanish, it would be helpful if there were a more fluent speaker. I joked that I could handle it, but only if she chipped in. After all, school hadn’t taught me anything more medical than “pregnant.”

We found her in triage lying in the only bed with stirrups. Her husband had rolled a stool over to the side of her bed and sat there with both of his hands cradling hers. When we walked in, he swiftly stood up to offer us his seat. Siéntase por favor, señor, I said, staying him with a hand before we introduced ourselves. As I tend to do in any situation demanding translation, I began by using the same phrase. “I’m sorry for my Spanish. I know I don’t speak perfectly but I’m going to try. It’s possible that you will need to speak slowly for me, okay?” Usually I get a smile and a mumbled gracias, then we slowly proceed. Rosa was particularly gracious and we made it through the first few minutes of the interview in modest fashion. However, though I could ask “Are you bleeding right now?” or “Do you feel any pain in your abdomen?” I’d never learned “cervix,” “uterus” or “vagina.” And so, after gleaming what we could conversationally, I admitted to Minnie that we should call a language line with her cell phone. Through it, I was embarrassed to learn that it’s cerviz, útero, and vagina.

The translator told us that she had been bleeding a lot. Más de un período. She had vague, nondescript abdominal pain that was getting worse. Her body spoke fearfully too: her eyebrows were knitted and slightly raised, her lips were pursed, her fingers, restless. Her husband stayed quiet, his hands folded over hers, eyes fixed to the floor. We asked her if the pain felt the same as before. She nodded and whispered the answer to her husband as if he had asked. Lo mismo, como cuando perdímos el otro bebé. I could see Minnie’s jaw clench; my throat winced.

The translator’s voice cut out. We solicited Sprint with my phone, but with no luck. The anxiety in the air grew noxious, so we endeavored forward. We told Rosa that we’d like to perform a sterile vaginal exam. I used prueba instead of examen, and she smiled again. Prueba literally means test, as with a pen-and-paper, fill-in-the-bubble, multiple choice test. The mistake reflected not only my inexperience with the language but my unseasoned, short-white-coat, medical estudiante status. After all, I was still much more used to pruebas than exámenes. Blushing, I apologized again for my Spanish. Rosa waved me off, still smiling, and said está bien, está bien.

A few minutes later, Minnie withdrew her fingers from between Rosa’s knees, quickly slipping the gloves off so as to avoid showing the room that her hand was dripping with blood. Rosa grimaced, and I will never know if it was due to the pain of the examen, or the dread of guessing what we would say next. Minnie whispered to me that we needed some imaging; we didn’t know where the bleeding was coming from; the pregnancy could be ectopic, and for now we had a “pregnancy of unknown location” that needed to “declare itself.” “We need to do an ultrasound” I explained, slurring the pronunciation of ultrasonido.

The black-and-white monitor revealed a nearly vacant uterus. Minnie glanced sideways at me, a wordless confirmation. Rosa was expressionless.

I knew what would come next. I had just read about it, not twenty-four hours ago. We needed to repeat a serum β-HCG level in two days. If the pregnancy were cleanly aborted, which at this point might be her best-case scenario, the levels would drop precipitously. I tried to explain to Rosa that she needed a “blood draw” in two days. Miraculously digesting my broken phonemes and strange vocabulary, she asked me why. Minnie and I looked helplessly at each other, silently agreeing to excuse ourselves saying lo siento, no podemos explicar muy bien. Tenemos que buscar para otra persona que puede traducir. It was not an admission of defeat so much as a recognition that the hardest part of this conversation shouldn’t be — wouldn’t be — the words themselves. Thankfully, by an enormous stroke of luck, one of the desk clerks outside spoke fluently. She looked like a teenager; I think I caught a glimpse of “Intro to Biology” homework tucked underneath her keyboard. Unflinchingly, she agreed to help us, communicating our message to Rosa at a speed I could only comprehend, not produce. Half of me listened while the other half worried about whether I should have sought her out earlier. I had been nervous about overstepping, about being overconfident in my abilities. I didn’t want to cause delay or offense. But, upon clarifying the message, our young translator departed, and Rosa addressed us again. Muchas gracias por todo. Los veré en dos días, she said with a smile.

But Minnie and I didn’t see her in two days; we saw her the next night. She greeted us with an unhappy smile. She had bled more throughout the day, and her tone told us that she already knew what an ultrasound would confirm. Sure enough, the monitor showed that there was nothing left inside her útero. After suffering what is known as a complete spontaneous abortion, she wasn’t in any palpable pain, though her cheeks were tearstained and her husband wore the face of affectless misery. Minnie cursed to herself. I murmured that I doubted we would need a translator. Minnie agreed. We didn’t have to use medical Spanish this time. All we needed was “sad,” “I’m sorry,” and “You are so brave.”

And so, I told her that she was brave. Valiente. Minnie told her that she was sad, me siento triste, and I apologized for her loss. Lo siento por todo que usted perdió. The word “abortion” was never used, partly because I didn’t know how to say it. Minnie furtively told me how crucial it was that Rosa understood this wasn’t her fault, so I emphasized. Es muy importante que usted sabe: no fue culpa tuya, entiendes? Minnie, in her long coat and all the pragmatism that comes with, told them that there might come a time when she would want to try again; if she wanted, we could offer her some tests, some more information, anything that might help. I supplemented, podemos ayudarles a ustedes, si quieres. I’m sure I got my tenses mixed up. I’ve never been very good at off-the-cuff conjugation, and I’ve only ever used the subjunctive or conditional tenses in homework assignments. I hope Rosa didn’t mind. I told her that she and her husband were strong. Ustedes son muy fuertes. When she began to ask about the future, Minnie and I re-iterated that medical testing might be una posibilidad to consider, but that the most important thing to do en este momento was to take care of her body, cuerpo, and her mind. I accidentally used the word cerebro, brain, instead of mente, mind, but no matter. And, as I turned to leave, I told her that her daughter, her little hija, was very lucky to have two parents like them.

It was a despairing moment: a woman and a man both stricken by loss, consoled by two white strangers with bad accents and limited vocabularies. But it wasn’t awkward.

I have worried about vocalizing that last sentiment: that their daughter was lucky. While I still feel it’s true, I have no idea what their feelings about parenthood were in those moments. I’m not sure they had enough time to feel much yet, beyond a numbing sense of pain and loss; it’s possible that it was tactless. When training with standardized patients, we students attempt to be as considerate as we can, careful not to make assumptions about what a patient might be experiencing or feeling. As a result, were I using English, I might have been more creative with my speech, more mindful of all the possible misinterpretations. But I also might have been less openly intimate, probably more reserved, hidden slightly behind the shield of a language that I am more comfortable with. Spanish expunged any chance of that. With Rosa, I couldn’t get any more complicated than my tongue would permit. And, for better or for worse, I ended up saying more.

As Minnie and I turned to create a wake for grief and peace behind us, Rosa called out to us tearfully. Ustedes son muy amables, gracias.

Por supuesto, de nada.



It’s been just over a year since that first night, yet memories of Rosa still keep me up at night sometimes. Every now and then, her voice echoes around my silent bedroom, not unlike the way that when I first started rotations in the hospital, it was difficult not to hear the ceaseless beeping of heart monitors as I tried to fall asleep. She is a sobering memory.

Re-reading the essay I wrote about her makes me squirm with discomfort, just like hearing how your voice sounds on a recording, or revisiting painfully-angsty pubertal diary entries. I dislike a lot about the way that I told her story – how the situation evolved, the decisions made along the way, and my reflection in the immediate aftermath. I thought I was telling a story about how a barrier gave rise to (what I felt at the time was) a uniquely intimate and honest conversation. But upon reflection, I think that by persisting with translating for her, my hubris bred myopia, and I may have done her a disservice. I wonder what I wasn’t able to elicit from her – I worry that my connection with Rosa was not forged in agreement or equivalence, and that the information I gathered was affected by language limitations and the context in which our conversation occurred. This lingering concern has, I believe, evolved into a hopeful determination to improve the way I connect with patients, to become more transparent and unfiltered, regardless of what language they speak, religion they practice, how they identify regarding gender or sexuality, or any other aspect of what makes them who they are.

One of the aspects that continues to bother me is that my immediate reaction to the dynamic with Rosa was akin to excitement: It was the first week of third year, and I reveled in the pathos of the experience with a distinctly “green” lack of self-awareness. Now, crystallized in text, that reaction has led me through an uncomfortable self-assessment. I am quite sad and disappointed that we didn’t stop to use a translator on that second day, but, just as viscerally, I carry some shame around how I initially internalized the story. In the essay, I made Rosa’s narrative about me; it’s so clear in how I wrote about it, about how I had tried x, y and z, about how I thought it went over well at the time. But, the truth is that I don’t know that and I never will.

So why do I write this postscript? I guess what I really want to say is that reflecting on my early training is not a discrete process. For which I’m glad, in a way. It has proven to be a continuous inquest to stay mindful of my limitations. For example, I have not only become more cautious about speaking Spanish in the hospital, reserving it for passing conversation, but I have also become much more tentative in celebrating what I perceive as a “successful” connection in an emotional encounter before I’ve taken the time to ask myself, “was this person served in the way that they wanted to be?”

Somewhere out there (or maybe somewhere inside me, I’m not totally sure which and it doesn’t seem to merit debating), there’s a doctor whom I aspire to be. I believe that Rosa’s voice, in concert with the voices of other patients’, past and future, will help guide me.

Names and other identifying information have been altered to protect the patient’s and resident’s identities.

Addendum added on 19 September 2018.

Andrew G (2 Posts)