Aortic dissection in the ED – Are they laughing at me?

As the world becomes smaller and our populations more multicultural (Yes I am a “Lefty” Mr Burley)… so communication in our emergency departments becomes even more crucial.

Last week whilst working in the UK, I was involved in the care of a young refugee from Eastern Europe who had not a word of English at her disposal. I’m sure everyone has had a consultation where very little in the way of effective communication has taken place – you try charades, signing, talking loudly and clearly in English and smiles…. But in the end, all that time you put in to learning history taking skills at university  – useless.

Now, in the ED we are used to a lack of information…. (Indeed I think if I have more than 70% of information on which to base a decision I fall into a apoplexy of indecision)…and that is OK; if you know that’s all you’ve got. But it becomes incredibly frustrating when you want to do the best you can for a vulnerable patient and you know your missing vital information because you just can’t get the message through a language barrier.

Back to the patient…There are not many people who can effectively communicate in Baltic state languages in our department so I attempted (for the first time) using “Language Line”. For those that don’t know – this is a telephone service that allows you to contact a translator for any language in the world (except perhaps some dialects in the North-east of the UK!). Once you have you have your translator you then spend an incredibly long time passing the phone between yourself and the patient whilst the person on the other end translates ever more personal information (all in complete confidence – so we are told – and with patient consent).

This is great, a revolution. Instant understanding. Verbatim translation…..Except… those moments when – and you’ve no doubt know it – the patient and translator have an incredibly long conversation and perhaps share a laugh…… and you get a classic one word translation in response.

You wonder… What were they talking about? Were they laughing at me? Have I got some food left around my mouth? And you start to get a bit uncomfortable….

Probably more important you think –  have I missed something?

So, the translator and the patient have a rapport, they share a laugh (perhaps at my expense) but you get a history to write down and everyone’s happy…. Except the real history is often hidden in the nuance of communication – the way something is said, the unspoken words, the carefully selected words, the language.

And we do miss vital information….

A very interesting paper from South Africa by Penn et al. has attempted to characterise the information we miss in translation. But, hold onto your hats it’s Qualitative Research.

From the outset I will say that its not specific to the ED, but the findings are interesting and can be related to translation of all sorts.

What the authors did was record healthcare interviews performed “pas de trois” (their French term not mine), i.e. doctor-patient-translator. Using the interview transcripts they have then decided selected what they term “asides” – times when the translator and patient communicated between themselves and not involved the doctor. They have then taken these asides and classified them as “big talk” (topics like patient beliefs about illness, relationship issues, disclosure issues) or “small talk” (topics such as transport, weather, clarification requests).

Asides were rarely translated for the doctor (even when directly asked)…. And here’s the thing – these nuanced conversation pieces were judged to contained vital health related cues that were never triggered by the doctor in the rest of the consultation. For example, in one consultation a patient discloses information  regarding who has knowledge of her HIV status – and the fact that a partner might not know, which was never relayed to the doctor.

These were issues that gave insight into the patient’s true agenda but weren’t brought out in direct conversation only these non-interpreted “asides”. The treating doctor was left none-the-wiser. Being qualitative there are no hard outcome measures – just developing of these themes…however, this is all interesting stuff because it gives us 2 useful insights:

  1. That we must beware of the translated consultation – we are missing the point!!
  2. History taking (even in your mother tongue) is more than just about asking textbook questions – patients are constantly giving us social cues and clinically important information from each and every aside…. We had better be listen carefully.

So next time you’re in a translated consultation and the patient and translator laugh at you… They probably are laughing at you… But be sure to ask why…



Cite this article as: Tom Bartram, "Aortic dissection in the ED – Are they laughing at me?," in St.Emlyn's, August 2, 2012,

1 thought on “Aortic dissection in the ED – Are they laughing at me?”

  1. Prof Simon Carley

    Hi Tom,

    Very thought provoking, although I must admit that lots of the patients seem to be laughing at me regardless of native language 😉

    Seriously though, have you had any experience in Google translate (or equivalent)? I have had concerns as you are never quite sure that electronic translation may miss subtleties….but if that is similarly the case with real translators it may be no worse.



Thanks so much for following. Viva la #FOAMed

Scroll to Top