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Improve ER Operations: Learn the Challenges for Interpreters in Emergency Services

Hi, I’m Jason, Account Manager for CyraCom with over 15 years of experience in the healthcare and interpreting industry. I recently gave a presentation at the 2013 DiversityRx Conference, entitled “Interpreting in Emergency Services: Challenges for Face-to-Face and Telephonic Interpreters.” Below is a summary of that presentation.

You will learn:

  • 11 common challenges that interpreters face when interpreting emergency services
  • Recommendations for how to work through these challenges

Introduction
Interpreting during emergency services encounters is not typically emphasized as part of standard interpreter training programs. These encounters may take place in the trauma bay of an emergency room, by phone with paramedics in the field or in an ambulance, or by phone with 9-1-1 dispatchers or poison control center operators. This presentation will familiarize healthcare providers with the basic procedures followed by emergency services staff and to address the difficult and challenging nature of these interpreting encounters.

Background
Here is the standard scenario:
On-site interpreters (including hospital staff interpreters, contractors, or agency interpreters) or telephonic interpreters are called to the bedside when a limited-English proficient (LEP) patient arrives in the Emergency Department/Trauma Center. Emergency Department staff begins by determining the mechanism of injury from a list of many possibilities including the following: motor vehicle crash, auto-pedestrian accident, auto-bicycle accident, motorcycle crash, burn/inhalation, gunshot wound, fall, stabbing, hanging, amputation/crush injury, assault, near drowning, poisoning/overdose, etc.

The trauma leader (e.g., trauma surgeon) is in charge of the conducting the primary survey which consists of the following questions (A-E): Airway: is it intact?, Breathing: are the lungs functioning?, Circulation: is there a pulse/heart rate?, Disability: are there good motor functions?, Exposure of injury: where is the injury located, and is it necessary to remove clothes, backboard, etc.? The trauma leader continues with questions as the recording nurse assists with capturing information in the written or electronic medical record.

The interpreter addresses either a conscious patient or a family member (if the patient is unconscious, intubated, or unable to speak). The following questions are asked: What was the mechanism/location/approximate time of injury? Was the patient wearing a seat belt or helmet? Was an airbag deployed? Was the injury self-inflicted? Are there special needs (LEP, hearing, sight)? What is the patient’s identification (name, date of birth, gender, weight, etc.)? When was the patient’s last meal? Are there any allergies? What current medications is the patient taking? What is the patient’s medical history?

Challenge #1: Positioning
For the interpreter, physical proximity to the patient is critical for effective communication. Interpreters struggle with the “ideal” position nearest the head of the bed without obstructing others. Other high-priority functions occur at the head of the bed: anesthesiology (e.g., intubation), respiratory therapy, insertion of chest tube/central lines, medication administration, etc. Interpreters must strive to find the optimal location to stand depending on the constantly changing environment.

Challenge #2: Multiple Providers
Providers from a variety of medical specialties and support services may be present during a trauma. In some cases, upwards of 15-20 hospital staff members may be providing care and services for the patient simultaneously. These may include staff from surgery, nursing, anesthesiology, respiratory therapy, radiology, chaplaincy, social work, EMS, police, and many others. Interpreters must be able to pay attention to questions and answers from this large group of hospital staff.

Challenge #3: Critical Time Frame
In extremely urgent cases, the trauma leader and other providers begin the primary survey before the interpreter arrives or before a telephonic interpreter is contacted. Critical background information may be lost to the interpreter, and the fast pace of the trauma room may significantly affect communication. The interpreter may be forced to modify his or her technique in some cases. When this happens, the interpreter must strive to adhere to all standards of practice and code of ethics while keeping up with the pace of the situation that is unfolding at rapid speed.

Challenge #4: Flow of Communication
As multiple providers work quickly to complete their assessments and interviews, the interpreter may be pulled in many directions at the same time. Providers may shout out questions simultaneously. Interpreters must strive to control the flow of communication, asking providers to speak one at a time, always in consecutive mode whenever possible. Critical, time-sensitive situations may force the interpreter to switch into simultaneous mode.

Challenge #5: Excessive Background Noise
The nature of the ER/trauma room creates excessive background noise that may affect communication and/or distract the interpreter. This noise level is increased by the presence of multiple providers, a general loud volume of speech and possible shouting, equipment and monitors, the patient’s pain level and emotional state (e.g., crying, shouting), and the presence of adjacent family members or other patients in the trauma bay.

Challenge #6: Emotional Nature of the Encounter
The emotional nature of many encounters in the ER/Trauma Center may affect the interpreter’s performance. Near-death situations can drastically increase stress and anxiety. Is the interpreter distraught? Is the patient distraught? Is the family distraught? Are children involved? Are the physical injuries disturbing to view?

Challenge #7: Personal Protective Equipment (PPE)
Interpreters may be required to wear Personal Protective Equipment (PPE) during a trauma. PPE may include masks, face shields or goggles, gowns, gloves, leaded x-ray aprons, etc. The use of PPE may also become a stressor for some interpreters and could affect performance.

Challenge #8: Special Needs of Family Members
During and after ER/Trauma Center encounters, family members may be faced with special needs that involve the interpreter: contacting friends and family by phone, contacting clergy or other religious support, conversations with law enforcement, conversations with chaplains and social workers, end-of-life/funeral arrangements, etc.

Challenge #9: Telephonic or Video Interpreting Equipment
The use of telephones and telephonic interpreters can also create unique challenges. With the use of speakerphones, sound quality may be affected. Proximity of the phone equipment to the patient is crucial. The volume of speech in the trauma room must be maintained at the lowest level possible in order to clearly hear an interpreter over the phone. Background noise becomes an even more critical factor.

Challenge #10: 911 Calls and Poison Control Centers
Telephonic interpreters also face challenges during 9-1-1 emergency calls with LEP patients. During high-stress situations, callers may not provide the information to the dispatcher in the order in which questions are asked. Telephone interpreters must triage what they hear and then provide the most critical information to the dispatcher first.  Sometimes it may be necessary to use summary interpretation when time is critical. A tone of voice that is appropriate for the emergency situation must be used. The interpreter should report any background observations, sounds, or conversations that may be important to the dispatcher. Interpreters must remember that the dispatcher’s goal is to get help to the patient as quickly as possible. Similar to 9-1-1 calls, telephonic interpreters may be used to communicate with LEP patients who call Poison Control Centers; specialized terminology may be necessary.

Challenge #11: EMS in the Field
Telephonic interpreters may be used in the field with first responders. Interpreters may be connected to first responders via cell phone or EMS radio at accident scenes, crime scenes, in the LEP patient’s home, onboard an ambulance, etc.

Recommendations

  • Clear identification of the interpreter when he or she enters the room/trauma bay is vital.
  • There must be clear identification of the trauma leader and the interpreter should always make an introduction to the leader. There should also be clear identification of the recording nurse and introduction by the interpreter.
  • The interpreter must strive to control the flow of communication among multiple providers; optimally one question at a time should be asked of the interpreter.
  • Trauma team education is the key; inform them that things will work differently with an interpreter!
  • The most experienced interpreters will perform the most efficiently under stress. Novice interpreters may need repetition and clarification, and time may not allow for this.
  • Additional training specific to Emergency Services may be developed for interpreters.
  • A collaborative effort between Language Services and Emergency Services departments is ideal in order to create a “team spirit” and to achieve optimal outcomes.

I would like to thank my good friend, Dr. Rachel Tuuri, a pediatric emergency physician at the Medical University of South Carolina, for her guidance and suggestions on this project.

Jason Roberson works as an Account Manager for CyraCom. Before joining CyraCom, he worked for Pacific Interpreters as the Southeast Region Manager and Training Manager of Interpreter Programs. Jason lives in Charleston, SC and was previously the Coordinator of Interpreter Services at the Medical University of South Carolina. He also taught college-level Spanish and linguistics for 12 years and has graduate degrees in Spanish Linguistics from Penn State University and in Hispanic Civilization from New York University. Jason has worked as a medical interpreter and a court interpreter in Georgia, Pennsylvania, and South Carolina. He served as a board member and the co-chair of the Membership Committee of the National Council on Interpreting in Health Care (NCIHC) from 2007-2011.

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