CARTing a Medical Evaluation
By Cathryn Bauer
CART use is spreading as more deaf and hard-of-hearing persons discover its benefits. This means that CART providers increasingly find themselves in novel and challenging situations. As we carry our equipment and unique service into unfamiliar surroundings, our clients and other involved individuals may occasionally find themselves struggling to understand our function and how they should relate to us. The CART provider must be prepared for more than just writing realtime.
Our foundation for professional practice is the set of guidelines provided by NCRA. It states clearly that a CART provider must be able to control emotions, and that we must stay in role during assignments. These judicious and realistic guidelines can be difficult to follow at times, particularly if we see those clients being treated badly by others.
A recent experience at a medical evaluation center is such an example. It consisted of two evaluators on two different days. The first evaluator my client and I encountered was unfamiliar with deaf needs, but wanted to adapt in order to meet my client's needs and the evaluation went smoothly for all concerned. The second evaluator unfortunately did not exhibit such openness, making an already difficult situation more painful for my client and an ethical and emotional challenge for me. She was not only ignorant of deafness, but displayed an unusual callousness toward my client despite his evident crisis. Regardless, it was necessary for me to work with her to adapt the test modalities for use with CART. The evaluation would strongly affect the outcome of my client's claim for damages sustained while employed. My own natural anger toward the evaluator had to be suppressed so that I did not influence my client's attitude toward the test. Further, interpreter ethics required me to stay in role, meaning that I facilitated communication without influencing the process. This required a great deal of adaptation on my part.
The First Experience
I received a call from a court reporting agency I'd worked with before asking if I did realtime. One of the deponents had "a hearing problem" and would need to look at my screen. A few hours later, I was walking into a large medical office in a nearby city. The receptionist directed me to a well-dressed man who appeared to be in his late 30s. She said, "Trevor really can't hear anything." He was writing on a clipboard. I walked over to him, waited for him to look up, and signed, "Hi. I'm the CARTer." Trevor rose, beamed, and shook my hand. Since my pidgin Sign vocabulary didn't cover much further discussion, I sat down alongside him, then got pen and paper handy.
After a few minutes, the receptionist called us, and we were escorted into an office with desk and chairs. The neuropsychologist, a kindly looking man in his 60s, sat behind the desk. I set up, arranging my screen so the client could see it. I asked where the attorneys were, and the neuropsychologist told me that they would not be present. This was just for communication between himself and Trevor. "Do I look at the screen?" he asked me. "Only if you want to," I replied.
The neuropsychologist interviewed Trevor, asking for his memories regarding a severe head injury he had sustained while doing skilled assembly work at a nearby manufacturing plant. I had encountered head injury patients before. Since I knew that focusing was very hard work for them, I was careful to avoid unnecessary movements or changes to the screen that might make the situation harder for Trevor. The neuropsychologist asked about his living situation, the circumstances of the divorce that had happened while Trevor was in a state hospital, and his assessment of his capacities. Trevor paid careful attention and gave complete, cogent answers. At the end of the interview, the neuropsychologist described the testing that Trevor would undergo at the end of that week. It would involve questionnaires and memory and problem-solving tests. He reassured Trevor that these were tests that couldn't be failed; they were designed to assess the capacities he had following his accident. Both patient and doctor thanked me politely when the examination was over.
The Second Experience
When I returned home, there was a message from the agency. Could I CART the testing? Yes, I could. So a day later, Trevor and I met again in the lobby of the medical office. We waited while the receptionist called the very late testing psychologist to determine her whereabouts. She was instructed to start Trevor off with a series of written examinations. Well, that was transcript editing time for me. Two hours later, the testing psychologist entered the office. She was reluctant to speak with Trevor directly. "You can talk to him," I told her. "He reads lips very well, and I'll fill in what doesn't get across." I was instructed to set up in her office.
The office had file cabinets, a medical examination table in the back, and a desk with two chairs in front of it. I put the screen on the desk, facing Trevor and me. When the testing psychologist came in, I asked her whether she needed to see his face throughout, thinking his emotional reactions might be important to her. She said no, he just needed a space to write. She asked whether I could erase text during tests of his memory. I suggested that she signal to me if she would like the screen closed and out of his sight.
The testing psychologist read an anecdote about a cafeteria worker who was robbed. She asked Trevor to repeat back to her as much as he could remember. She wrote down his responses, then read a second anecdote about a man whose evening out was delayed by a thunderstorm. When he was finished with his responses, she asked him to repeat his recollections of the first anecdote concerning the cafeteria worker. She wrote down his responses, then read a second anecdote about a man whose evening out was sidetracked by a thunderstorm. When he was finished with his responses, she asked him to repeat his recollections of the first anecdote concerning the cafeteria worker. She wrote down his responses, then read a second anecdote about a man whose evening out was delayed by a thunderstorm. When he was finished with his responses, she asked him to repeat his recollections of the first anecdote concerning the cafeteria worker. Next came a series of timed tests. Trevor was to count aloud by threes for one minute, then count backwards from 100 for another minute. He counted slowly and deliberately, his voice becoming anxious as he groped mentally for each number.
Next, the testing psychologist brought out a booklet. It had cartoon drawings of various objects including tools, household objects, various types of vehicles and dwellings. She flipped the pages forward as he named the item depicted in the pictures. Once these were completed, it was time for more abstract tests. Trevor had a minute to name all the words he could think of that began with the letter C. He gave this distressing task his full effort and concentration. As he choked out his fifth and final C-word, I noticed that the testing psychologist seemed to be trying to catch my eye. I was shocked to see that she had an expression of amused contempt. I looked away from her and adjusted my screen as she announced Trevor's next task, listing all the words he could think of that began with L. He managed several. Out of the corner of my eye, I saw that he seemed to be trembling. After listing three or four, the testing psychologist clicked on her stopwatch. Trevor told her, "Forgive me for this. I just feel real bad. I feel like I want to do more, but what I feel and I can do is two different things." She replied in a flat voice, "I'm sorry. I'm sorry you're feeling bad. Let's take a 10-minute break. Get some fresh air and some water." She then hurried out of the room.
Feeling that Trevor could use a few moments of privacy, I held up my phone and pointed to it, then to the door. He nodded and dabbed at his eyes. I walked outside the building to check my messages and return a call from the agency. When I returned, Trevor was standing in the lobby looking a bit more composed. I handed him the notebook and pen we had used earlier. He wrote, "It's like they expect me to walk, and I have no legs." I wrote back, "You know there are rules about what I can say to you. So I can't talk about the test or the psychologist. But that doesn't mean I don't care. And you can tell me anything you like about it." He nodded and began to talk about how he remembered when he worked, and had two cars, and was very good at numbers and mechanical tasks. I listened intently, knowing that attention was all I really could do for him. I did not want to help him with the test or influence his attitude toward the examiner. Ethics aside, the test results would affect the amount of his settlement and, I guessed, influence the type of care and treatment recommended to him.
About 20 minutes after she had first dashed out of her office, the testing psychologist came up to us in the reception area. Completely ignoring Trevor, she told me there was another test we would need to adapt given the use of CART. She would read him sequences of numbers which he was to recite back to her. I replied, "Sure, I can just close the screen quickly. I'll sit a little closer to it. Here, I need to let Trevor know what's going on." She snapped back almost angrily, "He doesn't need to hear this!" I decided the best response to her dismissal of him was a nonresponse. I moved over to Trevor, pulled out the notebook, and wrote, "We have to adapt another test." He smiled and nodded, and we followed the testing psychologist back into her office.
"Now, just one more test…" she said. She read a short string of one-, two-, and four-digit numbers to Trevor. I wrote the numbers, then leaned forward and pushed down the screen. Trevor managed several of the numbers. This test continued for several minutes. Then she said again, "Just one more test." I thought about asking for a lunch break, but decided otherwise. Since it seemed to be almost over, I would just hang in there instead of speaking up; speeding up this unpleasant proceeding seemed to be the best choice for both Trevor and I at that point.
There was another couple of hours of tests. After the rest of the memory tests, she asked Trevor to do simple calculations in his head. These were followed by several paper sheets of similar calculations which he was to do using a pencil. While Trevor completed the worksheets, the testing psychologist was up and down from her desk, filing, setting out a series of colored blocks and booklets in front of him, and talking on her cell phone.
"Just one more test," she told him. Trevor was to arrange the blocks in conformity with the pictures she placed in front of him. Again and again, the task was too much for him. He nevertheless gave it his best effort, going as far as he could with each of the drawings. He sat there miserably as she put the blocks and booklet away.
"Just these questionnaires," the testing psychologist said at last. Finally, it seemed, this really was the last test. These consisted of questionnaires that Trevor could work on independently under the supervision of the receptionist. I went to the bathroom. When I came out, the testing psychologist left. Trevor was working on the questionnaires at a desk in the waiting area. I walked over and stood in front of him, placing my hand flat on the desk within his range of vision. Trevor looked up from his paper and smiled at me. We shook hands. I looked into his face, making sure that he could see my lips before I said, "Good luck, Trevor." He put both hands around mine as he said, "God bless you."
Interpreter ethics do not allow intervention when a hearing person behaves thoughtlessly toward our clients. As our NCRA guidelines point out, it is up to us to stay in role and control emotions. Situations such as these can really challenge that ethic. It was difficult to watch my client being treated with such ignorance and callousness by a mental health professional, an individual who might reasonably be expected to know better. But more direct intervention on my part would have been not only a violation of professional ethics. It would also have affected his attitude and thus his performance. So my personal reactions simply had to be set aside.
CART is often perceived and marketed as a rewarding career that changes lives. But providing effective CART service is often, as this experience illustrates, a complex and difficult task.
About the Author
Cathryn Bauer, RPR, is from Danville, Calif.