The limitations of Wong-Baker

I was getting patient report during an early orientation shift at an ED nursing travel job in New England. The nurse reporting off added as an afterthought..."oh, and you may have trouble communicating with "John". If a family member's not there you may need to call the translator."

I went and assessed my patients, had a nice conversation with "John", and came back out to touch base with my preceptor for the day. "Oh, and "John" is doing well, no nausea, vitals are great, and he needs a little more pain medicine."

"So, family was still there?" she asked.

"No, he stepped out, but he'll be back in a few minutes." And no, I don't know "John''s language. Within a few minutes I found myself explaining to a new staff how I came to be semi-fluent in medical pantomime.

It was difficult for them to wrap their American medical minds around a place where ATT translators are not readily available. Where we hire aides for their language skills rather than medical knowledge and background. Where conversations may go through multiple nurses, translators, and other patients or family members. Where a little girl and her uncle could spend a month on a ward with no one who spoke their language, and our one translator for them came

down a few times a day; where complex sterile dressing changes, NG feeds and assessments could take place with little or no verbal communication if necessary.

And so in an effort to convey the challenge and the reward of care in this environment, I found myself telling them about Sayeed.

Sayeed was born nine years ago into a society and culture where any physical disability could be fatal. Babies with any deformity could be thrown out on the belief that they were cursed; even if the family kept a child he became a liability because the family had to care for his needs. Until May, Sayeed lived life on his hands and knees.

I first took care of Sayeed just as he was coming out of the recovery room. His beautiful innocent grin lit up his face, a response to my welcoming smile as he rolled in the doors of B ward. One of the translators was next to me for this first crucial moment - an initial set of vitals and assessment, explanation of postop procedures, circulation checks and pain medicine. Reassurance that he would have his own legs back and they were indeed still there under the strange hard whiteness of the casts. He wiggled his toes, giggled and gave me a thumbs up when I pinched them, and pointed to the smiley face (0) on the Wong-Baker pediatric pain scale, then settled in happily coloring.

I opened his chart to look over the postop orders and stopped, half-stunned, at the medical history: cerebral palsy. Only the strong love of a mother and the grace of God could have brought him this far in the villages of West Africa. I glanced over at his bed and he gave me a brilliant smile and thumbs up, then went back to coloring.

He breezed through the first few hours after surgery with no complaints, no problems, no need for pain meds. Around dinnertime I went to check on him again, a routine becoming familiar to him by now. He turned on the pulse ox and put it on his finger, put the thermometer under his armpit and held it there until the beep. Vitals...WNL. I pinched his toes and wiggled my fingers. He grinned and wiggled his toes, gave me a thumbs up. CMS checks...good.

Finally I pulled the laminated Wong-Baker faces scale off the wall and ran my finger along it. Are you having pain, Sayeed? He pointed to 4, a slightly sad face, and gave me a happy smile. I pointed to the 4, shrugged and looked confused, and ran my finger along the scale again. Are you sure you are having 4/10 pain? Again the nod, beautiful smile, finger on the 4. Then he went back to coloring with his mother.

Confused, I called over one of the translators. "Yaovi, can you ask Sayeed if he is having pain?" I asked. He came back with the same answer, "A 4, Afua."

"But Yaovi, he looks very cheerful. Can you ask him again if his legs are paining him and if he would like some paracetamol?" He did. "Afua, he says his legs do not hurt, and he does not need medicine."

Now I was really confused. "Then why did he tell me it was a 4? Can you ask him what he thinks the faces mean? Yaovi did, and came back laughing uproariously. "I think he does not understand the faces, Afua. I have taught him again what it means."

I found out later that the faces meant something a little different to Sayeed than what Wong and Baker initially had in mind. The zero- I am having a lot of fun; a two - I am having fun. A four...I'm a little bit bored.  I love the pure, uncomplicated mind of this little boy who was completely unconcerned that he would be the object of horrified pity in my country, a symbol of family shame in his.  He didn't know that he had just had surgery and by any stroke of logic he should be thinking about his legs, crying, fighting the nurses....instead, in total innocent oblivion he trusted that we would fix his legs.  And in the meantime, he just wanted to play!

Sayeed hanging out with a few of his friends at the Hospitality Center, including Bo, Komla and Abe. Photos by the ever-talented Liz Cantu.