Sofia Morales was a young woman who lived
in Atlanta, Georgia. She worked in a factory and studied at a community college. She had
recently moved to the US and spoke Spanish as her primary language, but tried practicing
English with classmates in the evenings – mostly through a group text chat – when she felt
motivated. One morning, Sofia woke up and noticed that her left wrist was hurting and
that there was a lump there. She had felt the pain before, but it was the large lump
that had her worried. “Could this be a tumor?” she wondered aloud, as she picked up the phone
to make an appointment to have it checked out. A few days later, Sofia went to see her primary
care physician, who examined her wrist. With the help of a Spanish language interpreter,
her doctor reassured her that it was most likely a ganglion cyst and not a tumor. Her
doctor also suggested that she get the cyst surgically removed and set up an appointment
with the orthopedic surgeon. Sofia went home feeling relieved that it wasn’t a bone tumor,
and was glad that it would get removed. Two weeks went by – and Sofia went with her
younger sister to visit the orthopedic surgeon. Dr. Margo, an orthopedic surgeon, who examined
Sofia’s wrist and agreed that she needed to have the cyst removed. Dr. Margo didn’t
have an interpreter with her, and was in a rush to get back to the operating room so
she asked her teammate, Dr. Alex Hammond, to take over. The conversation was quick “Spanish-speaking
woman, wrist surgery – cyst removal. You got it?” “Yep, wrist surgery, got it.” Dr.
Hammond responded. “She’s in room 2. Get the consent and schedule the procedure, thanks
so much!” she trailed off as she walked away. Dr. Hammond was feeling overwhelmed. He was
hoping to wrap up some clinic notes and wanted to get to the post-operative unit to see another
patient, but now he had to take care of one more thing. It had been a stressful day. He
hasn’t had time for breakfast or lunch and his stomach was reminding him that it was
4pm. He went in to room 2. “Hello – I’m the orthopedic surgeon Dr. Hammond, I’m
here to help you get set up for your carpal tunnel release procedure. Dr. Margo has filled
me in and I’ll be doing the procedure.” Sofia stared blankly not understanding a word.
He gathered himself “Do you speak English?” “A little.” “Hmmm… okay…” He thought
about getting an interpreter, but that would take up to 30 minutes, so he turned to Sofia’s
sister, “Do you speak English?”. “Yes – a little bit” she replied. “Perfect!
I won’t have to wait for the language interpreter.” He thought as he pulled out the surgical consent
form for Sofia to sign. He forged ahead with a mixture of English directed at Sofia’s
sister, and hand gestures directed at Sofia. He pointed to the signature block – “You’re
going to have carpal tunnel surgery for your wrist – he pointed to his own wrist.” Sofia
nodded. “Can you sign here to say that you’re okay with me doing the surgery?” Sofia grabbed
the pen and signed. Dr. Hammond smiled and reminded her to come on Friday at 8am – holding
up 8 fingers. On Friday morning, Sofia came early to the
orthopedic clinic for her procedure. Dr. Hammond performed the procedure and a few hours later
Sofia came out with a bandage on her wrist and headed home. At the follow-up appointment, Dr. Hammond
unwrapped Sofia’s bandage. Sofia looked at her wrist for the first time and to her
horror, right next to the surgical scar, was her ganglion cyst! She was confused and upset,
and a Spanish interpreter was called right away. With the help of the interpreter it
became clear that Dr. Hammond had done a carpal tunnel release surgery, which is a procedure
she didn’t need, for a problem she never had. Meanwhile her actual problem – her ganglion
cyst – was right there staring back at her. Dr. Hammond was quick to point out that she
“got the procedure she consented to have” and in the months that followed a lawsuit
would arise. Now – to rewind this back – let’s imagine
that Dr. Margo had given Dr. Hammond a less rushed signout and that he had repeated back
more completely what he had understood. He might have realized that Sofia had a ganglion
cyst. Later when he went to talk to Sofia, he could have gotten a medical interpreter
and taken the time to make sure that Sofia understood the procedure that she was signing
the informed consent form for. She would have probably wondered why she’s getting a carpal
tunnel release when her problem is a ganglion cyst. Dr. Hammond might have also taken that
opportunity to ask follow up questions and examine her wrist. At that point, she would
have been scheduled for the correct surgery. Finally, as he went in to do the surgery if
he had reviewed her chart or done a physical exam he would have seen that her problem was
a cyst and not a carpal tunnel release. Any of these might have prevented the medical
error and the lawsuit would have probably never happened. The moral? When taking over
a patient’s care, review their medical history thoroughly, perform a physical exam as appropriate
and always get a medical interpreter to remove language barriers.