An Intoxicating Error: Mistranslation, Medical Malpractice, and Prejudice

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Preface

Willie Ramirez is arguably the single most important medical malpractice case related to language. As a result of an interpreting error, Willie’s brain hemorrhage was misdiagnosed and he was left quadriplegic.

On January, 22, 1980, 18-year-old Willie Ramirez ate a fast food hamburger. That evening, he fell down unconscious and his Cuban family thought it was the hamburger that made him sick. They tried to explain to the emergency room doctor that he was intoxicado, which in Cuban Spanish means ill due to something one ate. The medical history was provided in a chaotic and confused manner with various family members using limited English to describe what happened. Willie’s teenage girlfriend mentioned that they had been arguing, which caused the ER doctor to piece together a story that was completely wrong. He thought Willie was intoxicated—that he had taken an intentional drug overdose because he was upset about the fight with his girlfriend. No qualified interpreter was called because the parties believed they were communicating adequately.

Although not consciously prejudiced, the doctor was influenced by an implicit association between drug abuse and young Cuban men. But Willie was a health-conscious athlete who never used alcohol or drugs. Willie was mistakenly treated for a drug overdose while his brain continued to hemorrhage.

The interpreting error was compounded by a series of mishaps. Willie was admitted to the intensive care unit by an upper-class, Spanish-speaking Bolivian doctor who failed to confirm the medical history because he was uncomfortable with the working-class Cuban family. The entire medical team who attended to Willie accepted the initial diagnosis of drug overdose and did not question it until the patient nearly died. Everyone missed the signs of the brain hemorrhage for 36 hours. When it was finally diagnosed, surgery was performed to stop the bleeding, but it was too late and Willie was left quadriplegic. The all-star baseball player and architecture student would never walk again.

Willie’s case is unusual, only in the gravity of the outcome. The U.S. Census Bureau estimates that 21 percent of people age five years and over speak a language other than English at home. Of these individuals, 13.6 million people speak English not well or not at all.¹ Most of these people do not have access to qualified medical interpreters when they become ill and must rely upon family and friends to interpret, just as Willie did. Competent medical interpretation goes well beyond simple language ability. Qualified interpreters are able to convey the message between two parties without adding, omitting or changing anything that was said. They allow the patient and healthcare provider to have the same conversation they would have if they spoke the same language. Training and hiring qualified interpreters is expensive, and there is little support for using public funds to pay for it. Advocates for the use of qualified medical interpreters use Willie as a poster child for their cause. His is the most frequently cited case of a medical interpreting error that led to a bad outcome.

After the legal settlement was announced in the local paper, Willie disappeared from the public eye. Only his family members and close friends knew how to contact him. Willie’s story is a useful one—a story that can frighten people into getting trained interpreters. Like other advocates, I wanted to use him for this purpose so I dug up old newspapers, court records, and deeds and found him.

It was 2008, 28 years after the interpreting error. Armed with an address I hoped was correct, I drove around a middle-class neighborhood in Miami looking for the house. My heart skipped a beat when I saw the handicapped plate on the van in front. This must be the right place. I knocked on the door firmly and a pleasant-looking, short-haired, 70-ish Cuban woman opened the door and looked at me suspiciously. I stepped back to give her space and blurted out in Spanish, My name is Gail Price-Wise. I am writing a book about Willie. I sent a letter but received no answer and thought I would come by. She stepped outside and closed the door behind her. She said, I am Willie’s mother. We received your letter. What do you want?

I chose my words carefully, aware that if she turned me away, I wouldn’t get another chance to research his story and to write about it. I said, Señora, thank you so much for talking to me. I work in Public Health and I am trying to improve care for people from other countries who don’t speak English well. I am hoping to learn more about what happened to Willie as a way to help others. She looked at my face to assess my intentions and then invited me into her living room. She said, Willie is away, but I’ll call him. Reaching him, she said The woman who is writing the book is here to talk to you, and handed me the phone. Thus began many, many hours of interviews.

When I met Willie in person for the first time, I was struck by how imposing a figure he was, dressed in a formal suit and black shiny shoes. He sat in his wheelchair reclining at a 30-degree angle and, in this position, took up much of the small room so that one had to maneuver around him. His attendant placed Willie’s arms in his lap so they wouldn’t hang by his side. I didn’t know how to arrange myself so we could speak eye to eye, and I couldn’t hide my discomfort as I sat and then stood and then sat again. The window shades in the room were down and I walked over to raise them, even though it wasn’t my house. I needed to bring more light into the room to ease my distress. As he often does, Willie calmly acknowledged what was difficult to say. You looked shocked. Are you okay? I wanted so much to convey warmth and acceptance, but all I did was trip over myself.

Through the years, our meetings have become decidedly less formal. I arrive and sit by Willie’s bed. He’s often in his underwear, covered by the sheets. The head of his bed is raised. I find the hum of the electric air mattress comforting, knowing that it continually shifts the pressure under his body to prevent the formation of sores. Our conversations are unhurried and comfortable.

My initial interviews with others have been equally challenging. Willie’s doctors were not happy to receive my call. The ER doctor said, I’m not sure I recognize the name ‘Willie Ramirez.’ Can you refresh my memory? I quickly replied, I am SO sorry to bother you. I don’t mean any harm. I am writing a book about the Ramirez case and want to understand what happened to prevent it from happening again. I would be very grateful if you would speak to me even for a few minutes. With obvious trepidation, he acknowledged that he was indeed the doctor I was looking for and agreed to speak with me. He was deeply moved to learn that Willie had gone on to live a relatively normal life—even to marry and have a biological child. Hearing that, he was willing to share information. The attending physician, in contrast, was as angry about the lawsuit as if it had happened yesterday. The malpractice case had marred his entire life. These doctors shouldered the responsibility for the system-wide errors that led to Willie’s misfortune. There is no reason to cause them any further grief and so I have used pseudonyms and have changed some of the details about them.

Unfortunately, by the time I started my research, most of the legal records had been destroyed. Thankfully, Willie’s lawyers reached back into their memories to describe as much as they could about the lawsuit. They were clearly proud of the favorable settlement they were able to negotiate on Willie’s behalf. Without their adroit legal skills, Willie’s life story would have been very different. Money does not solve all problems, but it can make them smaller.

Through my interviews, I learned that it was not only the interpreting error that caused the malpractice, but a perfect storm of miscommunication and mistrust fueled by intercultural tensions and flaws in the healthcare system. The comprehensive picture of what happened in the hospital before and after Willie’s diagnosis and treatment show how a multitude of circumstances come together to determine a patient’s fate.

Many of the people who surround Willie have also faced challenges associated with intercultural mistrust. I have included their stories in the book to create a fuller picture of what it is like for outsiders to live among English-speaking Americans of European descent. As I did for the doctors, I have used pseudonyms and have altered some information about them out of respect for their privacy.

Willie’s family and friends have been extremely generous in their willingness to share personal information. With the exception of the doctors, everyone I spoke with described the special person Willie is and how he had contributed to their lives. They also spoke almost boastfully about what they had done for Willie. Such boasting is not mere vanity. It is a testament to how desperately people want to give something meaningful of themselves and to be recognized for it.

Over 30 years as a quadriplegic, Willie has become an extraordinary person with rich intercultural relationships and a philosophical perspective on his limitations. "An Intoxicating Error: Mistranslation, Medical Malpractice, and Prejudice," is the story of how language barriers and prejudice affect his life and the lives of those around him.

Chapter 1

The Calamity

I think I went in and out of consciousness. I remember a white coat. I think they were slapping my face. They were yelling, What did you take?! What did you take?! When I woke up, I didn’t know where I was. I already had the surgery, but I didn’t know anything. I didn’t know I was in a hospital. I didn’t know I was quadriplegic.

—Willie Ramirez

Willie Ramirez awoke, climbed out of bed, and walked to the bathroom to urinate, just like every other morning. But this would be the last morning he would urinate standing in front of a toilet. Beginning the next morning, urinating would be through a catheter while lying in bed or reclining in his wheel chair. It was January 22, 1980. He was 18 years old, handsome, athletic, and adept at getting women to fall in love with him. Willie had graduated from Miami South Ridge High School the previous spring. A mediocre student, Willie was known in school for his John Travolta thick black hair, good looks, and his career as an all-star baseball player. It was hard to decide which was more dear to him—his baseball glove or his blow dryer. At the time of his injury, Willie was a student at Miami Dade College, studying to be an architect. He balanced his studies with a full-time job at Service Merchandise Catalogue Showroom in the sporting goods department. He had chosen the job so he could get health insurance.

"That morning, I went with my girlfriend Cristina, my sister Ivette, and my Mom to look for banquet halls for Ivette’s debutant or ‘coming out’ party. For Cubans, this is supposed to be a big formal event, with people in tuxes and everything. There was a cruise shipped docked called the ‘Miss Florida’ boat where they did parties. We went in my car to see it—Ivette, Cristina, my Mom, and me. Me and Cristina went out a lot with my sister, since Cuban girls weren’t allowed to go on a date without a chaperone. We were alone together only a few times, with threats from her parents about behaving in an honorable way. After seeing the boat, we went to the new Wendy’s on US 1. I had a hamburger and a chocolate Frosty, the first and last meal I ever had at Wendy’s. Afterward, Cristina said she wasn’t feeling well so I took her home and I went over to Service Merchandise. I liked to go there even when I wasn’t working to hang out with the other employees my age. A lot of people that worked there would go out to a bar, called The Hideout, after the store closed. I wasn’t a drinker, so most of the time, I didn’t go. When I did, I would sometimes have one whiskey sour. But that night, I had an iced tea."