Cultural Issues in the Emergency Setting

CASE 1: MISTAKEN ETHNICITY

A 55-year-old man, identified as an African American, presented to the ED accompanied by a staff member from his nursing home. His daughter-in-law had placed the patient in this facility 3 weeks earlier, after it was concluded that he was no longer able to care for himself.

Immediately after arrival at the nursing home, the patient demonstrated odd behaviors, according to the staff. Many times during activities, he was observed "talking" to the sky, small animals, and plants. Once he was heard asking for "the wolf" to heal him. Another nursing home staff member noted the patient dancing in his room in an erratic, circular pattern. She heard him repeating phrases that seemed nonsensical. He often smelled of garlic, a supply of which he had hidden in his room. When a worker attempted to remove the garlic, he yelled and then struck her, prompting this evaluation.

At the ED, the patient appeared guarded. He sat still, speaking softly without spontaneity. He was respectful toward the examiner. He had a colorful bag around his neck, containing multiple small items, including feathers, stones, and strong-smelling herbs.

When asked about recent events in the nursing facility, he stated, "The Great Spirit will soon release me." When asked about this spirit, the patient's flat affect brightened. He recalled time spent as a young child listening to the "headman" speak of a spirit who had power over all things. He grew up respecting the universe as a whole, which is why he communicated with plants and animals. The psychiatrist asked the patient if he was American Indian and not African American. He replied simply, "Yes."

The patient had been registered at the nursing home by his daughter-in-law, who was African American. Rather than asking the patient what his ethnic background was, the nursing home and later the ED staff assumed his cultural identity. When his behaviors were evaluated in the context of his American Indian culture, they were not viewed as odd.

The patient was discharged with a small dose of a minor sedative. The nursing home staff was reminded of the need for accurate assessment of ethnic identity and given a strong recommendation from the ED psychiatrist to engage the patient in culturally relevant dialogues, with the aim of obtaining the most accurate information about the patient's behaviors.

Discussion

In the ED setting, demographic information is often presented to the consulting physician rather than being independently obtained. Cultural or ethnic identity often plays a significant role in the patient's outlook on events, symptoms, and health care providers.¹ In this case, assuming the patient's ethnicity resulted in the misperception of behaviors and potential for diagnostic errors.

American Indians, in general, have distinctive beliefs about nature, including animals, plants, and inanimate objects. To heal disease and ward off ghosts and destructive spirits, American Indians may collect various objects--such as herbs, pollen, oddly shaped stones, and various body parts of animals (eg, bones, teeth, feathers).² These objects are often stored in a "medicine bag," such as the one this patient was wearing around his neck, and kept for protection of an individual person, a family, or the community.

In the context of the patient's culture, his behaviors were neither bizarre nor psychotic and did not warrant traditional acute management of psychotic conditions--namely, parenteral administration of fairly high doses of antipsychotic medications. Instead, educating the nursing home staff and his peers about his beliefs and teaching them ways to recognize and discuss them would be the best approach.

Interpreters or cultural consultants and educational agencies often perform this educator function and foster didactic efforts. If these services are not immediately available, community and educational agencies might embrace this opportunity to sponsor appropriate cultural awareness exercises.

CASE 2: DENIAL OF SUBSTANCE- INDUCED PSYCHOSIS

A 19-year-old Somali man was brought to the ED by his parents, who spoke limited English. The ED psychiatrist requested an interpreter, but the patient's parents were initially reluctant to accept one. After much discussion and persuasion, they agreed.

The patient sat in a corner of the examination room looking back and forth and appeared to be grasping at objects in the air. The psychiatrist attempted to approach him, but the patient responded with fast speech in his native language. The interpreter told the psychiatrist that the patient's speech was illogical and nonsensical. The psychiatrist tried to gather more information from the patient's parents; they denied that their son had any history of medical or psychiatric disorders.

The psychiatrist then asked the interpreter to inquire whether the patient had used any illicit or other substances. The interpreter looked at the psychiatrist and stated, "He is Muslim and does not use Western drugs." The patient's parents nodded in agreement. Despite the physician's insistence, the interpreter refused to ask the patient about drug use.

The interview was interrupted as the patient began to pace and speak loudly. He repeatedly banged his head against the wall. Because of these actions, he was treated with an intramuscular injection of haloperidol, along with lorazepam and diphenhydramine. He did not respond immediately to the medications and became increasingly agitated, thus requiring a second dose of the medications. After an hour, the patient's agitation decreased. The decision to admit him to an inpatient unit was made. However, the hospital was at capacity, so the patient was housed in the emergency treatment unit overnight.

During the night, one of the patient's college roommates visited. He reluctantly informed the treatment team that the patient had ingested khat for the first time at a party about 2 days ago. The roommate stated that immediately after ingestion, the patient complained of gastritis and retired to his room. Early in the morning, he and his other 2 roommates were awakened by the patient speaking loudly while sitting alone in a darkened room. They were afraid to approach him. They also feared that their own drug use would be discovered, so they failed to seek medical assistance. After a neighbor complained about the noise, they transported their roommate to his parents' home.

Discussion

The drug known as khat, which is frequently abused by young Somalis in communities throughout the United States, has amphetamine-like properties. As with other stimulants, use of khat may lead to a psychotic or manic episode.³ With long-term use, patients may develop a pervasive state of delirium.

Khat is a product of Catha edulis, a large shrub that originated in Ethiopia and then spread to other East African countries, such as Somalia. Native Africans often chew the leaves--a socially acceptable practice in various countries in Africa and the Middle East, where the use of khat is likened to drinking caffeinated coffee or chewing tobacco. This substance is not controlled and, therefore, may be found in ethnic food markets.³ As a stimulant, it produces feelings of exaltation and liberation from space and time. It also produces extreme loquacity and inane laughing. Excessive use may lead to a comatose state.

The possibility that the patient might have used khat was a key piece of information that a rigid, zealous interpreter overlooked or ignored. This was compounded by the fact that drugs such as khat may not be included in a typical drug screen.

Practitioners must carefully screen patients for drugs of abuse, particularly adolescents and young adults, immigrants, and children of immigrants^4,5 who present to EDs in metropolitan areas. In many ethnic groups, persons may misuse or abuse substances that are endemic in their native country and available in ethnic markets in the United States. In addition, persons from these groups may not consider the use of such substances to be inappropriate.

Often, when the patient does not speak English well, interpreters are used, rather than family members. Medical interpreters should transcribe verbatim the patient's utterances and assist with the psychiatrist's understanding of cultural subtleties not easily negotiated through language. Interpreters should not offer answers on behalf of the patient that are based on their personal judgments and morals. If the patient is from a small community, he or his family is often hesitant to use the services of an interpreter, fearing a lack of confidentiality protection, particularly if the interpreter does not follow an objective approach.

This case shows that the use of interpreters in the ED may be a decisive factor affecting the accuracy and promptness of diagnosis and subsequent therapeutic interventions.

CASE 3: ATAQUE DE NERVIOS

A 23-year-old Hispanic woman presented to a local ED accompanied by a friend. The patient had been in her usual state of health until 3 days before, when she was seen crying quietly and then uncontrollably, pacing in an agitated state, and periodically inflicting superficial cuts to her upper extremities.

In the 3 days before this ED presentation, the patient had been referred to the emergency treatment unit on at least 5 separate occasions, with complaints of nausea, chest pain, and diaphoresis. On 2 occasions, she had lost consciousness, experienced intense shaking for 2 or 3 minutes, then regained consciousness and described feeling "better." At each visit, the medical evaluation was unremarkable. Several diagnostic studies were completed, including an ECG with rhythm strip, a complete blood cell count, measurement of thyroid-stimulating hormone level, and a chest radiograph, all with normal results. On this sixth ED admission, the staff consultant requested a psychiatric evaluation. The patient was interviewed after being given 0.5 mg of lorazepam to manage her increased anxiety.

The patient was resting quietly on a hospital gurney, holding her friend's hand. Examination of her upper extremities revealed several recent acute lacerations. Her friend left the area as the psychiatrist began the evaluation. The patient denied any previous psychiatric history. When questioned about the symptoms leading to her emergency evaluations, she could not recall the surrounding events. In fact, she felt as if the behaviors described by her family and friends were performed by someone else using her body. Occasionally she would pause, then lie in a fetal position; after a period of silence, she would begin to speak again.

The patient was engaged; she and her betrothed were raised in Austin, Tex, after immigrating to the United States from Cozumel, Mexico, in their mid-teens. They were reared as neighbors in a lower-middle-class community. She reported that her fiancé often yelled at her and spoke to her in a derogatory manner. Both the patient and her fiancé are recent graduates of a technical college. They planned to move to Arizona to find jobs and begin their life as a married couple.

A week before the onset of symptoms, her fiancé had been called to service by the National Guard. The couple was told of his deployment only 2 weeks before his scheduled departure. The patient apparently had coped well with the news, planning to use the time he was to be away to prepare for their nuptials.

Her friend was called in and questioned by the psychiatrist; she provided a similar history. The friend declared her pride in the poised manner in which the patient handled her fiancé's departure. She was concerned about the patient experiencing a heart attack, because the patient's mother died of heart disease in her early twenties. Furthermore, she verbalized increasing resentment that a "shrink" had been consulted.

At that point, the patient began to cry loudly. She seemed overwhelmed and appeared to be in a state of panic; she hyperventilated and fainted. She received a second dose of lorazepam, calmed down, and started to talk spontaneously again. She was planning not to prepare for the wedding, believing that her fiancé "will likely die during his service." She feared his death would lead to her own demise, because she believes that she cannot function without him. She described her present feeling as reminiscent of the days immediately after her mother's death.

Discussion

This patient's syndrome is known as an attack of nerves, or ataque de nervios. A culture-bound syndrome included in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, ataque de nervios is common in patients from Latino and Caribbean communities and often is considered a psychiatric emergency.⁶ Its confusing features can be easily labeled as psychotic states, "hysterical" crises, or personality disorders characterized by emotional instability. Patients afflicted with this illness are generally women from low-socioeconomic-status groups.

The onset of ataque de nervios usually is related to recent stressful events, unresolved abuse, or perception of loss of control. Common signs and symptoms include dissociative episodes, amnesia, crying spells, screaming, agitation, self-injurious behaviors, syncopal episodes, and cardiac-like symptoms. The prototypical "ataque" consists of an overriding sense of loss of control, sadness, anger, and expressions of distress in the form of physical symptoms, aggressive outbursts, and loss of consciousness.⁷ Most of these attacks are triggered by a stressful family event, frequently a change in marital status. Patients often have comorbid anxi- ety disorders, usually panic disorders, and may speak of traumatic memories. Several of these features apply to this case.

In the ED, a key dimension of the evaluation must be the acknowledgment of the patient's stress. It is important to allow the patient to set the pace of disclosure. Unless safety concerns are imminent, the use of restraints should be avoided because they may trigger a sense of vulnerability that could acutely worsen symptoms. Low doses of medication are recommended; short-acting benzodiazepines are often prescribed to diminish acute symptoms. A referral to psychological services, including family therapy and cognitive-behavioral therapy, are first-line treatment modalities.

References:

REFERENCES

1. Siegel JM. A brief review of the effects of race in clinical service interactions.

Am J Orthopsychiatry.

1974;44:555-562.
2. MSN Encarta. Native American religions. Available at: http://encarta.msn.com/encyclopedia_ 761580498_5/Native_American_Religions.html. Accessed September 26, 2006.
3. Al-Kamel M. Khat plant. Available at: http:// www.geocities.com/forceps1974/khat.html. Accessed September 26, 2006.
4. Westermeyer J.

The Psychiatric Care of Migrants: A Clinical Guide.

Washington, DC: American Psychiatric Press; 1989.
5. Scuglik D, Alarcón RD. Growing up whole: Somali children and adolescents in America.

Psychiatry.

2005;2:20-31.
6. American Psychiatric Association.

Diagnostic and Statistical Manual of Mental Disorders, Text Revision.

4th ed. Washington, DC: American Psychiatric Association; 2001.
7. Guarnaccia PJ, Rivera M, Franco F, Neighbors C. The experiences of ataque de nervios: towards an anthropology of emotions in Puerto Rico.

Cult Med Psychiatry.

1996;20:343-367.