Of necessity, I speak pretty good Spanglish, I think, although my fluency seems lost on native Spanish speakers. While in Honduras, for example, I worked hard to open every patient encounter by asking everyone in Spanish why he or she had come that day. To a person, they all seemed puzzled by the question. It was only after the clinic was over that my amused translators told me that I had spent the entire day asking the patients, “Why am I here today?”

I did not make that mistake again, although I spent a good part of the next day asking the patients “How long am I here today?” I finally got the simple phrase “Por que estas aqui hoy?” down pat, but the answers sometimes surprised me.

“I wake up every morning and think about blowing my head off.”

That is what my first patient of the day told me through a translator. He was 79 years old, a weather- beaten, wrinkled old caballero with a rusted six-shooter tucked into his waistband.

“How long have you felt this way?”

“For many years.”

Uh-oh. As far as I knew there were no psychiatrists available in the mountain villages of Honduras, and we had not thought to stock anti-depressant medicines in our traveling pharmacy. Hundreds more patients were lined up waiting to be seen. I had to solve this ominous problem somehow. My translator was a University of Virginia student who grew up speaking Spanish at home (her parents were Peruvian) and she was quite fluent. I had her translate the complaint several times and each time it was the same. His very first thought every morning was blowing his head off. And yet something didn’t quite fit. The patient did not appear depressed and in fact was grinning and seemed delighted with the close attention he was getting from the gringo medico. I was missing something. I needed more than a translator. I needed an interpreter.

I called Pedro over. Pedro was a native of Honduras and our local fixer. If anyone could help, it was Pedro. He seemed to know everyone in Honduras and could talk to anyone. I asked Pedro to ask my ancient cowboy why he had come.

“He has a headache,” Pedro told me.

“Does he want to blow his head off?”

Pedro and the patient chuckled.

“No. He is saying his head feels like it’s going to explode. You know, blow up.”

“He has had headaches for many years. He has high blood pressure but can’t get any medicines for it because there is no doctor in his town. He wants you to prescribe him blood pressure medicine. That is why he is here.”

My translator was beet red. Yet it wasn’t her fault. Peruvian idiom is different than Honduran idiom and her translation was accurate but misleading.

Just to be certain he wasn’t thinking about hurting himself, and to get my translator back into the game, I asked her to ask him why he was carrying the gun. The cowboy patted the gun affectionately and gave me a toothless grin.

“Banditos,” he told me with a wink. He pulled his pistol with a flourish and offered it to me to inspect. It looked like a Civil War relic. Pedro confirmed that carrying such antiquated firearms was indeed a common and common-sense practice. Honduras has the highest murder rate in the world. Oh, boy. Well, at least I could treat his high blood pressure. That I understood.

Verbal translating and interpreting are closely related but sometimes critically different skills. Translating is generally word-for-word verbatim relaying from one (source) language into another (target) language. Interpreting is more likely to be paraphrasing what each speaker is saying. When done well, interpreting is more accurate than translating, but it requires a deeper fluency in both languages compared to translating, which requires less fluency in the source language, in this case Spanish. When trying to understand complex medical and social issues, especially in the time-pressured ER, interpreters are more helpful than translators, who are more widely available.

Early in my career, non-English speakers were not common in the ER and interpreting services in the hospital were not available. We improvised when language barriers arose. Spanish speakers could usually be found among the ancillary staff. Once when faced with a patient who spoke only Chinese, our triage nurse called the local Chinese restaurant and used the waiter to translate. Of course this is not HIPAA compliant, but the patient got the care he needed and we got General Tso’s chicken for lunch.

Times have changed. Now we have instant access to certified medical interpreters in over 200 languages via a subscription service on our ER telephones. It still amazes me to be able to get a Swahili interpreter on the phone in under 15 seconds. And yet interpreting across cultures still presents challenges and we still improvise. I recently saw a lady from Thailand who had a sore throat. The Thai interpreter on the phone couldn’t really understand the woman except to ascertain that she was Burmese; her stay in Thailand was at a Burmese refugee camp. The Burmese interpreter also could not understand the lady but concluded that she spoke Karen, the language of a small ethnic minority in Burma. To my delight, our translation service had a Karen translator on retainer and she answered promptly. Unfortunately she spoke a different Karen dialect than the patient and they could not understand each other, despite growing up in villages in Burma only 15 miles apart. But the translator had a cousin in her neighborhood who spoke two Karen dialects but no English. With the patient’s permission the cousin came over to the translator’s house and translated from Karen into Karen and the translator translated from Karen into English and back again into Karen-Karen. Phew. I have no idea how much of my explanation of a viral throat infection was lost in translation, but my prescription for Tylenol seemed to impress.

On our last day in Honduras we set up clinic in a closed school. I was presented with an 8-year-old girl whose grandmother explained that she was there because she was missing school. This is a somewhat common pediatric complaint in the U.S. too. School phobia, or didaskaleinophobia, affects two to five percent of U.S. kids and I thought I was on firmer ground.

“Why has she been missing school?”

“Because it is Christmas Break and school is closed for a month. When she heard you were coming today and opening the school, she insisted on putting on her school uniform and coming in to see if your clinic was anything like school.” Oh, right, missing school. The little girl hung around with us all day, enjoying her day at school.