In Compliance

Those familiar with language access issues in healthcare have probably heard about the famous “intoxicado” case. If you’re not familiar, here’s a brief recap: 18-year-old high school sports star, Willie Ramirez, arrives comatose to the ER. None of his Cuban friends and family members speak English (either at all, or at least not proficiently). One of them tells the ER staff that Willie is “intoxicado.” In Cuban Spanish, “intoxicado” means “I got sick from something I ate or drank,” like food poisoning or an allergic reaction.

Based on the word “intoxicado,” and scant information that Willie and his girlfriend had been arguing, the ER doctor diagnosed Willie with a drug overdose, i.e. “intoxicated.” Willie actually had a blood clot in his brain. It took 36 hours for someone to figure that out – despite numerous clean tox screens – and by then, it was too late. Willie left the hospital (a year later) a quadriplegic. Eventually, he settled his medical malpractice claim for $71 Million.

… The Rest of the Story

Recently, I had the great pleasure of reading “An Intoxicating Error: Mistranslation, Medical Malpractice, and Prejudice,” by Gail Price-Wise. This book, published in 2015 (35 years after Willie’s hospitalization), provides substantially more detail about what actually happened to Willie on the fateful day he arrived in the ER, and then follows his life over the next 35 years, including going back to school, getting married and having a biological daughter.

In the many articles about “the intoxicado case” you can find on the Internet, the primary focus is on the misinterpretation of the word “intoxicado.” No medical interpreter was used, and many of the articles focus heavily on the misinterpretation of this single word as “the” cause of Willie’s misdiagnosis.

In her book, Ms. Price-Wise, however, points out some things that I did not know and had not considered about Willie’s medical treatment: the major role stereotypes, culture and prejudice took in Willie’s case.

Let’s look at some seemingly disparate facts: Willie lived in Miami. In the 1980’s, the Miami drug scene was pretty terrible. Shows like “Miami Vice” often portrayed Latinos, in general, or Cubans, specifically, as drug users, drug dealers and drug lords. Willie’s girlfriend was a traditional, Cuban girl, subject to strict dating rules (think: chaperones). However, Willie “went out with” some American girls, who were considered “loose” – a sort of “dirty little secret” that everyone knows about, but no one talks about – and certainly not welcome around Willie’s family.

The book explained that, in Cuban culture, people (especially women) typically defer to the decisions of an authority figure, like a doctor, and may not speak up to contradict what a doctor says. Many Bolivians consider Cubans to be working-class, boisterous, and improper, and tend to act with an air of superiority toward them. Bolvians speak Castellano, a dialect of Spanish, but consider it a higher form of speech, much like the Queen’s English versus everyday slang. So how did these disparate these things affect Willie’s diagnosis and care?

How Culture and Prejudice Contributed to Disaster

  • Culture Eliminates Eyewitness: The only person to be there when the sharp pain, disorientation and nausea hit Willie was the American girl he was seeing. She had also been with Willie for hours, and knew he hadn’t taken any drugs. Because of strict cultural rules, Willie couldn’t have this girl drive him home or to the hospital. So, she wasn’t there to tell the ER doctor what had really happened.
  • Stereotype Clouds Initial Judgment: The ER doctor explained that when a young, comatose, Hispanic male comes into the ER, a brain hemorrhage is not the first thing that comes to mind. In other words, the assumption was very strong that drugs must be involved in ER cases with young, male Latino patients.
  • Culture Prevents Clarification: When the ER doctor told Willie’s mom and girlfriend that the diagnosis was drug overdose, they accepted it. Both were too timid to contradict the doctor and too shy to speak up and say that athletic Willie had never and would never do drugs.
  • Prejudice Prevents Communication: Willie’s treating physician (after he was admitted to the hospital) was Bolivian and actually spoke Spanish. But he spoke Castellano, not “Cuban Spanish,” and simply refused to deal with the “rude and undignified” “mob” of Cuban friends and family members there for Willie. So, he just went with the ER doctor’s diagnosis. Had he tried to get additional medical history, he might have learned that Willie had been having headaches and that Willie was an athlete and strongly against drug use.

The misinterpretation of the word “intoxicado” played a huge role in the misdiagnosis of Willie Ramirez. But culture, stereotype and prejudice were right there alongside, creating a perfect storm of miscommunication and mistrust that resulted in Willie permanently losing all feeling below his neck.

Never Again!

Playing the “what if” game doesn’t give Willie Ramirez his mobility back. But looking at what happened to him can and should result in healthcare professionals everywhere vowing, “never again!” One step toward “never again!” is to include culture competence in healthcare language access training.

Training should include not only include the important aspects of culture from the predominant LEP populations in your area, but also when and how to ask your professional medical interpreters for assistance with cultural brokering. Remember: your professional medical interpreters are not there just to interpret words. They are there to make sure that your patients are not only heard, but understood.


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