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.