Romualdo Rivera arrives at the emergency room with what seems to be a complaint of chest pain. But it's hard to be sure — he doesn't speak English.
He's a pale but solidly built man with thinning, gray hair, and his face reddens as his shirt is removed, his pant legs are pushed up and electrodes are attached to his calves and chest.
As nurses and technicians come and go from the small, curtained examination area, his eyes dart from one person to the next, hoping for a familiar phrase, even a word.
Unlike TV portrayals of frenzied big-city emergency rooms, the scene slows in real-life hospitals when a doctor and patient can't communicate. It becomes like a game of charades, as one doctor put it, with lots of pointing and gesturing.
Nationwide, the approach to care for non-English-speaking patients is hit-or-miss. Fewer than a fourth of U.S. hospitals have professionally trained interpreters, a study found. In some places, hospital employees with no medical training are called in to interpret. In others, relatives, neighbors or acquaintances do the job.
In the worst cases, the patient's problem gets lost in translation.
Hospital officials realize they need interpreters, but most haven't figured out how to pay for them. The Temple University Health System took action when two hospitals had a surge of Spanish-speaking patients.
Now, Temple and nine other medical institutions nationwide are taking part in a program that could show why hospitals can't afford to be without formally trained medical interpreters.
From 1990 to 2000, Philadelphia's Hispanic population rose from roughly 89,000 to 129,000, or more than 44 percent. Many settled in neighborhoods around the two Temple hospitals in north Philadelphia.
In a relatively short time, patients from Puerto Rico, Mexico, Dominican Republic, Central and South America were accounting for 20 percent of all admissions, said Charles Soltoff, a Temple executive.
"Because so many of them spoke little or no English, we weren't able to serve their needs as well as we wanted to," he said.
So this past spring, Temple hired four interpreters with an $850,000 grant from the Robert Wood Johnson Foundation and began sending them to medical classes.
Temple and the other hospitals getting grants must develop a comprehensive medical interpreting program. They've also been asked to document how trained medical interpreters affect patient care and hospital costs.
Health care advocates are convinced that having no interpreters means longer stays, unnecessary tests, more repeat visits and even medical mistakes.
Hospitals have long relied on friends or relatives of patients to help translate, but it's an arrangement that comes with risks.
Patients sometimes hide details from children or friends filling in as translators. And sometimes family members want to shield patients from unwelcome news from their doctors, said Marbella Sala, who manages medical interpreting services at University of California-Davis.
"We had a case where a patient was being treated for a venereal disease and asked the doctor how she could have contracted it. The doctor explained it, but her husband, who was interpreting, told her that she got it from a public toilet," Sala said.
The doctor suspected something was amiss and an interpreter later cleared things up.
UC Davis has one of the nation's largest and oldest medical interpreter programs. Established in 1987 with a staff of seven, it now employs 42 people who speak 19 languages — from Spanish and Russian to Hmong and American Sign Language.
"It has made us the place of choice for many patients," Sala said.
As he waits for a doctor in the ER at Temple University Hospital, Rivera stares at the ceiling, holding his side with one hand.
His face brightens when Carmen Diaz, dressed in yellow scrubs like Temple's other medical interpreters, begins translating for Dr. Jason Bell.
"How does it feel? Is it crampy? Dull? Sharp?" Bell asks.
"Que tipo de dolor es?" Diaz says. "Siente calambres en el estomago? Es un dolor leve o agudo?"
Rivera, an elderly man who declines to give his age, replies in Spanish.
"It's like a headache pain; a dull, achy pain," Diaz translates.
The Q&A continues as Rivera's blood pressure is taken, his pulse checked, his respiration monitored. Where is the pain? Does it hurt to breathe? Any fever? Chills? Palpitations?
Bell concludes that the problem isn't Rivera's heart but his stomach. X-rays, blood work and a CAT scan are ordered.
Without interpreters, Bell says later, doctors must resort to "a lot of pointing and charades."
"It's very difficult to get an adequate (medical) history from patients who don't understand what they're being asked," he said. "When we can home in on whatever the problem is, it makes it easier to provide the proper treatment, and it cuts down on unnecessary testing."
Diaz, 27, has worked as an interpreter at Temple since April, but it's a job she has been doing most of her life.
"I know what it's like to be 9 years old and to be interpreting for people," she said.
Cultural training also is an important part of the Temple program.
"Lots of cultures believe in the evil eye and that staring at a baby can bring harm to it," said interpreter Jaime Molyneux, who works in maternity services at Temple. "Some people also get upset if you touch the baby's feet, because they believe it can stunt their growth or cause a stutter."
Modesty or gender roles also come into play — some women are wary of divulging personal information or undergoing exams by male gynecologists, for example. And attitudes on breast-feeding and circumcision vary widely.
After giving discharge instructions to one young mother, the 27-year-old Molyneux is called to translate for Veronica Diaz, a Mexican immigrant who has had a rough night after giving birth to her son, Roberto.
"Is it inflamed? Because I seem to have a lot of stomach," Molyneux translates from the new mother to Dr. Valentino Piacentino III.
Piacentino assures her that the swelling is typical and will go down.
"It's really simple: If I don't have Jaime, it just doesn't work," Piacentino says later. "In medicine, communication is everything. If I don't have a way to communicate with patients, I can't do much."
Since 2000, hospitals and private practices getting federal funds have been required to provide interpretation services under the Civil Rights Act. They've largely made do since then with untrained or undertrained people.
"For so long the myth has been that you could get by using friends, family members, staff; now there's growing understanding that that's not enough," said Sala, at UC Davis.
"We know what should be done, but the big issue is who pays for it? That question has not been answered."
Professional medical interpreters can earn $20 to $25 an hour.
Dr. Ricardo G. Unda, director of Temple's program, said it seems intuitive that the presence of interpreters would improve care and save money in the long run. But little hard data exist. Research suggests the more non-English-speaking patients you have, the higher the risk for error and poorer health care.
A small study published last year in the journal Pediatrics found that mistakes in interpreting were common, with 31 errors on average in each of 13 recorded doctor visits. About 22 percent of people with untrained interpreters, such as family or friends, had interpretation errors of potentially serious medical consequence during the visit, compared with 12 percent for those with a staff interpreter.
Professional, trained interpreters were found at fewer than one-fourth of hospitals, and most of that group had not received training in medical terminology.
The National Council on Interpreting in Health Care reports that many people who consider themselves bilingual are unable to pass the council's basic proficiency tests.
As Temple interpreter Diaz puts it: "To speak Spanish at the dinner table with your family is one thing. To speak in Spanish about gastrointestinal disorders is another thing."