The Case

A 62-year-old Spanish-speaking woman with a past medical history of hypertension and asthma presented to the pre-anesthesia area for elective removal of a left thigh lipoma. Expecting a relatively simple outpatient operation, the anesthesiologist opted not to use a Spanish language translator and performed a quick pre-anesthesia evaluation, obtaining her history from the medical record. Unknown to the anesthesiologist, the patient was trying to communicate to him that she had undergone jaw replacement surgery and that her mouth opening was therefore anatomically limited. There was no mention of this historical information in the surgeon’s preoperative note. During the airway exam, the anesthesiologist assumed that the patient did not understand him when she was asked to open her mouth wide.

The anesthesiologist proceeded with his plan for general anesthesia via laryngeal mask airway (LMA) placement after rapid induction. In the operating room after induction of anesthesia, he was able to open the patient’s mouth just enough to place the LMA, but he was unable to ventilate through it due to bronchoconstriction. Realizing that he would need to intubate the patient, he attempted direct laryngoscopy, but his view was severely limited, and he was unable to visualize the airway sufficiently for intubation. With the patient becoming hypoxic (i.e., oxygen saturation <90%) for about 5 minutes, he called for help, and eventually one of his colleagues was able to intubate the patient, although both of her central maxillary incisors were dislodged in the process.

After the operation, the patient was left intubated and admitted to the intensive care unit (ICU). She required ventilatory support for two days before she could be successfully extubated. The patient did not suffer permanent neurological injury from the prolonged hypoxemia, but she did require dental implants to replace the two dislodged teeth.

The Commentary

By Christian Bohringer, MBBS and Luis Godoy, MD

Background

Extensive migration of individuals to and from various parts of the world has established diverse and multicultural populations in many countries including the United States. The increasing linguistic and cultural diversity of our country has led to the potential for communication problems when providing care for our patients.^1,2 Difficulties occur especially after hours when interpreting services are not as readily available as during the day. Language barriers have been identified as a cause of adverse events and it has been suggested that hospitals consider improving patient safety systems for patients with limited English proficiency (LEP).³ To this end, AHRQ has produced the TeamSTEPPS® Enhancing Safety for Patients With Limited English Proficiency Module, which recommends that hospitals foster a supportive culture for safety of diverse patient populations; adapt current systems to better identify medical errors in LEP patients; develop institutional strategies to empower frontline staff and interpreters to report medical errors; develop systems to monitor patient safety among LEP patients, as well as processes to analyze medical errors and near misses that occur, and develop strategies and systems to prevent medical errors among LEP patients. These strategies “include strengthening interpreter services, improving coordination of clinical services, providing translated materials, and developing training for healthcare providers and staff on team communication, interpreter use, cultural competency, and advocacy.”

Health care providers are frequently under time pressure to bring the next patient to the operating room.^4,5,6 Therefore, there is the constant temptation to skip performing a thorough preoperative history and physical examination, in a misguided attempt to save time and money. With adequate preadmission planning, an accredited medical interpreter can be available in the preoperative area when needed, either in person or by telephone or video link. A thorough preoperative assessment by an anesthesiologist with the help of a medical interpreter for patients with limited English proficiency is necessary for safe patient care, as this incident clearly demonstrates.

In summary, this patient had five minutes of low oxygen saturations and lost two front incisors during a low-risk elective operation. If the airway problem had been elicited preoperatively, the procedure could have been performed with local anesthetic infiltration or a spinal anesthetic. Appropriate airway equipment could also have been ready for use in the operating room. Immediate availability of a videolaryngoscope and a fiberscope may have prevented dental damage as well as the prolonged episode of hypoxia with subsequent ICU admission for continued ventilatory support.

Approach to Improving Patient Safety

Adequate preadmission planning

In an elective surgical case, such as removal of a thigh lipoma, it is easy to anticipate prior to admission that an interpreter will be needed. If an interpreter had been scheduled to be present in the preoperative area for this elective operation, the airway incident in the operating room would probably have been averted. With adequate prior planning, arranging interpreting services for patients with limited English proficiency will not lead to delays in the operating room schedule.

 Accredited medical interpreters not only assist with language translation but can also help the care team to understand the cultural beliefs held by a patient from a different ethnic background. These cultural beliefs may be unfamiliar to most health care providers. Understanding the cultural context of the patient, with the help of the interpreter, can help providers to deliver more patient-centered care, enable shared decision-making, and ensure that informed consent is obtained.^7,8

For emergency procedures, prior planning is impossible, and the urgency of the procedure may preclude the involvement of a medical interpreter. However, the urgency of the procedure must be carefully balanced against the risks of not completing a thorough preoperative assessment and not having truly informed consent for whatever procedures are deemed necessary. Enlisting the help of staff members or relatives who speak the patient’s language may be helpful in a true emergency. However, properly trained and credentialed interpreters should be utilized whenever possible to ensure that patients of different cultural backgrounds receive the same level of care as English-speaking patients.

Utilizing Medical Interpreters Effectively

Medical interpreters are not utilized often enough when providing care for patients with limited English proficiency, and effective use of medical interpreting services has been recognized as a significant gap in undergraduate medical education.^9,10

Banks of interpreters who could speak to patients and providers by telephone have been available for decades. More recently, telemedicine has dramatically increased the availability of interpreters and the languages that are supported. During a virtual consultation via a computer screen, the interpreter no longer needs to be physically present in the examination room. In this way, a single medical interpreter can cover multiple care facilities that may be geographically separated. Video interpretation also allows the interpreter to gauge emotional reactions when viewing the patient’s face. The ability for each participant to see each other's faces humanizes the telemedicine experience and improves patient satisfaction. Clinicians have rated video interpreting services as equally good, compared with in-person services.¹¹ In one study from a large pediatric emergency department, quality-of-care ratings by LEP parents who received ad hoc or professional telephone interpretation was significantly lower than that of English-proficient parents who had no interpreter, but no significant difference was reported between LEP parents who used professional in-person interpreters and English-proficient parents. A systematic review reported that professional video interpretation was associated with better caregiver understanding of discharge information than interpretation by telephone.¹²

Completing a thorough preoperative anesthetic consultation

A thorough preoperative assessment is an essential component of providing safe anesthesia care for patients throughout the perioperative period.^13,14 Information obtained in the preoperative period may become crucial in the operating room or during the postoperative period. For this reason, the responsibility of obtaining such details falls on both the surgical and anesthesia care teams. Language barriers are a frequent impediment to providing safe care and every effort must be made to communicate with the patient in her or his own language with the help of an interpreter. The language that the patient feels most comfortable communicating in should be chosen as the basis for the conversation. This case illustrates that an interpreter must be present not only during the history-taking, but also during the physical examination portion of the encounter so that the patient can effectively cooperate with diagnostic maneuvers.

Health care providers should try to learn some basic medical words in languages that they frequently encounter at their workplace. For example, an interpreter is normally not present in the operating room, and some communication is necessary before the patient is anesthetized and after she or he emerges from anesthesia. When the patient is receiving monitored anesthesia care with light sedation, these language skills will also be very useful.

Ready availability of advanced airway equipment

Predicting difficulty with intubation by a preoperative airway exam is known to be unreliable even when the assessment is performed by an experienced practitioner of airway management.¹⁵ Therefore, an unanticipated “difficult airway” scenario following induction of general anesthesia may be encountered even after a thorough airway assessment has been performed. Equipment to manage an unanticipated “difficult airway” scenario, such as a videolaryngoscope and a fiberscope, should be readily available for use in the operating room.¹⁶

Registering the patient in a difficult airway database

It is important to realize that this patient will probably require other operations in the future and that mismanagement of her airway could lead to her death. The patient should be informed of what happened under anesthesia in the recent operation (with the assistance of a medical interpreter), the physician’s error should be fully disclosed, and appropriate compensation for her dental injury and implant surgery should be provided, if appropriate. The details of the case should be recorded online so that this information can be accessed by future anesthesia care providers.

Online difficult airway registries allow future anesthesia care providers to review problems encountered during a previous anesthetic even when it was performed in a different city or within another healthcare organization. Registration with a difficult airway notification service is now recommended in the latest American Society of Anesthesiologists “Practice Guidelines for Management of the Difficult Airway.”¹⁷ The patient sometimes only remembers that there was a problem but does not recall the details. Giving the patient a card with the access details for the online difficult airway registry and a MedicAlert bracelet can help transfer important airway information to future anesthesia care providers.

Conclusion

This patient was aware that her limited mouth opening resulting from previous jaw surgery was important information for the anesthesiologist and surgical team. Although she tried to convey this knowledge, she was unable to do so because the team decided to forgo the assistance of a professional interpreter. This case clearly demonstrates that a medical interpreter is an indispensable part of the health care team whenever providing care for a patient with limited English proficiency.

Take Home Points

• Medical interpreting services should be enlisted whenever there are any perceived communication barriers by either the patient or by any member of the health care team.
• Interpreting services should be scheduled prior to admission in order to prevent delays in the operating room schedule
• A thorough preoperative assessment by an anesthesiologist is an essential component of safe anesthesia care and should be performed in the patient’s own language with the help of a medical interpreter.
• A thorough preoperative assessment should also be performed by the surgeon in the patient’s own language with pertinent physical limitations and prior surgical history clearly documented.
• Advanced airway equipment should be readily available for use in the operating room to safely and effectively secure the patient’s airway in the event of an unanticipated airway problem.
• Patients with a difficult airway should be registered with an online difficult airway notification service to help future anesthesia care providers provide safe care.

Christian Bohringer, MBBS
Professor of Clinical Anesthesiology
Department of Anesthesiology and Pain Medicine
UC Davis Health
chbohringer@ucdavis.edu

Luis A. Godoy, MD
Assistant Professor
General Thoracic Surgery
Department of Surgery Diversity and Inclusion Director
UC Davis Health
lagodoy@ucdavis.edu

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