Blog — Clinical Spanish

Spanish for dialysis nurses: the 14-year-old who has been on dialysis for two years and whose mother answers every question directed at the patient, the transition conversation when the nephrologist says the adult program is eighteen months away, and the 9-year-old brother who pauses on “end-stage” because he does not know what to do with those words in front of his grandmother

Marisol Torres is 14 years old. She has been on hemodialysis for two years, Monday, Wednesday, Friday, diagnosed with focal segmental glomerulosclerosis at the end of sixth grade. She carries her backpack to the chair. She has one AirPod in and one out. Her mother, Graciela, 42, sits in the chair beside her and has been sitting in that chair for two years.

Who Marisol is

Marisol was diagnosed in the spring of 2024. She was twelve. Her mother noticed that she was swollen around the eyes and that she was not keeping up in soccer the way she usually did. The pediatric nephrologist at the children’s hospital told them she had FSGS and that dialysis was going to be necessary while they waited to see if a kidney would become available.

Graciela took a leave from her job at the school cafeteria. She has been at every session since the first one. She knows the staff. She knows the unit schedule. She knows which vending machine takes the dollar bills and which one doesn’t. She knows the names of the other patients in the unit and sometimes they talk while the machines run.

Marisol knows the machine. She knows what the different alarms mean. She knows the sensation of a session going well and the sensation of a session where something is off ten minutes before the machine says so. She missed the first three months of eighth grade and made it up remotely. She is in ninth grade now. Her grades are good. She wants to be a nurse.

On a Tuesday in March, the pediatric nephrologist comes into the unit mid-session to speak with Graciela about the transplant timeline. Marisol’s name has been on the waitlist for fourteen months. If a compatible kidney does not come before she turns 16, she will transition to the adult dialysis program. That is eighteen months away.

The nephrologist addresses most of what she says to Graciela. Marisol watches from the chair.

Failure mode 1: The nurse who talks to the mother

The nurse who walks in for the Tuesday session assessment greets both of them and turns to Graciela.

“¿Cómo ha estado Marisol?”

(How has Marisol been?)

Graciela answers. She says Marisol had headaches on Thursday evening and that her ankles were a little swollen on Sunday. She says Marisol didn’t sleep well on Monday but she thinks it was the math test, not the dialysis.

The nurse listens, charts what Graciela said, and turns to the machine.

Marisol has not said anything.

This is not a failure of the nurse’s attention. The nurse is not ignoring Marisol on purpose. She is doing what she has learned over two years of sessions produces the most complete and efficient report: asking Graciela. Graciela observes Marisol at home. Graciela tracks the symptoms between sessions. Graciela answers fully, in complete sentences, in Spanish the nurse can follow, without pausing to think.

Asking Marisol takes longer. Marisol sometimes says “bien” and waits. She is 14. She is in the chair. She is not sure what the nurse is actually asking when the nurse asks how she feels, because the nurse has not asked her how she feels in the way that suggested the nurse wanted to know.

The consequence is not visible in any single session.

The consequence is that Marisol, at 14, is learning that the nurses in this unit talk to her mother about her body. She is learning that the information about how she feels flows through Graciela. She is learning that when she says “bien” and her mother says “tuvo dolor de cabeza el jueves,” the version that gets charted is her mother’s.

By the time she is 15, Marisol has stopped volunteering symptoms she has not already told Graciela about. There is one that she hasn’t mentioned to anyone: a sensation in her right arm, near the access site, that feels different on Fridays than it does on Mondays. She told her mother once and Graciela said “lo digo a la enfermera” and then forgot. Marisol did not bring it up again.

This is what two years of talking-to-the-mother looks like.

Failure mode 2: The transition conversation that starts with logistics

On the Tuesday in March when the nephrologist explains the timeline, the charge nurse follows up with Graciela after the nephrologist leaves.

“Entonces, lo que esto significa es que vamos a empezar a preparar a Marisol para hacer la transición al programa de adultos. Van a conocer al equipo de adultos, van a visitar la unidad, van a hablar sobre las diferencias en cómo funciona todo. Es un proceso que toma varios meses. Nosotros vamos a estar con ustedes en todo el proceso.”

(So what this means is that we are going to start preparing Marisol to make the transition to the adult program. You will meet the adult team, you will visit the unit, you will talk about the differences in how everything works. It is a process that takes several months. We will be with you through the whole process.)

Graciela nods. She has questions about insurance, about whether the schedule will change, about whether she will still be allowed to sit beside Marisol the way she does now.

Marisol is in the chair two feet away. She has heard everything.

She has heard that she is going to be transitioned. She has heard that it is going to take several months. She has heard that they will be with her through the process.

She has not been asked what she thinks. She has not been asked what she wants to know. She has not been asked what she is worried about, or what she has already heard about the adult program, or whether the word “transición” means the same thing to her that it means in the protocol.

The logistics conversation is not wrong. The insurance question matters. The schedule question matters. The question about Graciela being present is real and practical and will need an answer.

But the logistics conversation with Graciela is not the transition conversation with Marisol.

Marisol has been on dialysis since she was twelve. She has known for most of ninth grade that the adult program exists and that it is coming. She has heard the other patients in the unit talk about the adult unit the way people talk about a different country: not bad, just different, and not something she has asked about because no one has asked her if she has questions about it.

The transition from pediatric to adult dialysis is not only a logistical event. It is the moment when a teenager who has been a pediatric patient since she was twelve becomes, in the eyes of the health system, an adult who will manage her own disease. It is the moment when the identity of “a child who has dialysis” has to shift into something else.

Marisol has not been given a frame for what that something else looks like.

She has been given a timeline and a list of things that will happen to prepare her.

Failure mode 3: Diego and the phrase he cannot carry

Abuela Rosa, Graciela’s mother, came from Oaxaca in January to be with the family. She speaks no English and is most comfortable in Spanish, though her first language is Zapotec. She comes to the Wednesday session when Graciela has a conflict.

Diego is Marisol’s brother. He is nine. He comes sometimes on Wednesdays because there is no one else to pick him up from school and Abuela Rosa cannot drive.

Diego is good at this. He has been doing it in various forms for most of his life. He translates for Abuela Rosa at the grocery store. He calls the phone company when the bill is wrong. He explains the school nurse’s notes to his grandmother because Graciela gets home after the school nurse’s office closes.

He is nine. He is very good at it.

On a Wednesday in April, the nurse who is assessing Marisol notices that Abuela Rosa is asking something through Diego. The nurse waits. Diego translates the grandmother’s question:

“She wants to know if Marisol is going to get better.”

The nurse pauses. She does not want to give Rosa something inaccurate. She knows Rosa may not understand dialysis the way Graciela does. She knows Rosa flew in from Oaxaca because her granddaughter is sick and she does not know exactly how sick.

The nurse says:

“Marisol está en lista para un trasplante. Mientras esperamos, la diálisis le limpia la sangre igual que lo hacen los riñones. Si recibe el trasplante, probablemente pueda dejar la diálisis. Lo que sabemos es que Marisol tiene insuficiencia renal crónica terminal y que la diálisis es su tratamiento permanente a menos que reciba un riñoacute;n.”

(Marisol is on the list for a transplant. While we wait, dialysis cleans her blood the same way the kidneys do. If she receives the transplant, she will probably be able to leave dialysis. What we know is that Marisol has end-stage renal disease and that dialysis is her permanent treatment unless she receives a kidney.)

Diego translates.

He says “trasplante” easily. He says “limpia la sangre” easily. He says “diálisis es su tratamiento” easily.

He pauses on “insuficiencia renal crónica terminal.”

He knows the Spanish. What he does not know is how to say it to his grandmother who came from Oaxaca to see her granddaughter and who is sitting across from him in a dialysis unit waiting to find out if the girl in the chair is going to be okay.

Diego looks at the nurse.

The nurse does not notice the pause. She is writing in the chart.

Diego says something to Abuela Rosa. He does not say “insuficiencia renal crónica terminal.” He says “que tiene los riñones muy enfermos.” (That her kidneys are very sick.)

Abuela Rosa nods. She already knew that. She asks something else.

Diego translates the question:

“She wants to know if the doctors think Marisol will get the transplant before she turns 16.”

The nurse looks up. She looks at Diego. He is nine years old. He has been in this unit for an hour. He came to pick up his sister because his grandmother cannot drive.

She says:

“Eso es una pregunta que merece una conversación más larga. Creo que la coordinadora de trasplantes es la persona correcta para responder eso. Le vamos a pedir a ella que hable con su abuela y con su mamá esta semana, con un intérprete profesional, para que Rosa tenga toda la información.”

(That is a question that deserves a longer conversation. I think the transplant coordinator is the right person to answer that. We are going to ask her to speak with your grandmother and your mother this week, with a professional interpreter, so that Rosa has all the information.)

Diego translates this one without pausing.

He is glad someone else is going to answer it.

The conversation that works: directing Marisol

The nurse who does this well does not do anything complicated. She makes a decision at the beginning of every session to ask Marisol first.

She walks in. She greets both of them. She turns to Marisol and makes eye contact.

“Marisol — ¿cómo te sientes tú hoy?”

(Marisol — how are you feeling today?)

Not “¿cómo ha estado Marisol?” directed at Graciela. Not “¿cómo están?” addressed to both of them and answered by the one who has been answering for two years.

Marisol says “bien.”

The nurse does not turn to Graciela.

“¿Algo que hayas notado desde el viernes?”

(Anything you’ve noticed since Friday?)

Marisol pauses. She says: “El brazo.” (The arm.)

“¿Tu brazo? ¿Qué sentiste?”

(Your arm? What did you feel?)

Marisol describes the sensation she has been noticing on Fridays. The nurse listens. She does not chart while Marisol is talking. She asks a follow-up question.

Graciela did not know about this symptom.

After Marisol finishes, the nurse turns to Graciela:

“Señora Torres, ¿usted ha notado algo en el fin de semana que Marisol no haya mencionado?”

(Mrs. Torres, have you noticed anything over the weekend that Marisol hasn’t mentioned?)

This is the sequence. Patient first. Mother second, explicitly framed as a supplement to what the patient said.

The nurse does not tell Graciela that she should not answer for her daughter. She does not explain the policy on adolescent autonomy or the hospital’s communication guidelines. She simply asks Marisol first, every time, in a way that makes clear that she is asking Marisol because Marisol is the one she wants to know from.

Within three weeks, Marisol starts answering in complete sentences.

The transition conversation that starts with Marisol

The nurse who has been asking Marisol first is the one who sits down for the transition conversation.

She does not pull Graciela into the hallway first. She does not deliver the logistics and then ask Marisol if she has questions. She starts where the conversation belongs: with the person whose life it is about.

“Marisol — quiero hablar contigo sobre algo importante. No es una emergencia. Es sobre cómo va a cambiar tu cuidado el año que viene. Y quiero que seas tú quien me diga qué quieres saber primero. Puedo empezar con lo que va a ser diferente. Puedo empezar con cómo funciona la transición. Puedo empezar con lo que no va a cambiar. ¿Por dónde quieres que empecemos?”

(Marisol — I want to talk with you about something important. It is not an emergency. It is about how your care is going to change next year. And I want you to be the one to tell me what you want to know first. I can start with what will be different. I can start with how the transition works. I can start with what will not change. Where would you like us to start?)

Marisol is quiet for a moment.

She says: “¿Voy a poder seguir viniendo los mismos días?”

(Am I going to be able to keep coming the same days?)

This is not the question the nurse expected. She expected the transplant question, or the question about what the adult unit is like, or the question about whether her mother can still come.

Marisol wants to know about the schedule because she has a biology exam on the third Friday of every month and she has arranged her study sessions around the Monday, Wednesday, Friday cadence. She has a system. She wants to know if the adult program is going to require her to rebuild it from scratch.

The nurse answers the question Marisol asked. She gives her the information she has about the adult program’s scheduling flexibility. She is honest about what she does not know and tells Marisol who can answer the rest.

Then she says:

“Marisol — llevas dos años haciendo esto. Empezaste cuando tenías doce. Eso significa que tú conoces esta máquina y lo que sientes en ella mejor que cualquier enfermera nueva que te vaya a cuidar en el programa de adultos. El equipo de adultos va a tener que aprender de ti. Eso es parte de lo que hace que esta transición sea diferente para ti que para alguien que acaba de empezar. Tú ya sabes cómo hacerlo. Lo que vamos a aprender juntas es cómo hacerlo en un lugar diferente, con gente que todavía no te conoce.”

(Marisol — you have been doing this for two years. You started when you were twelve. That means you know this machine and what you feel in it better than any new nurse who is going to take care of you in the adult program. The adult team is going to have to learn from you. That is part of what makes this transition different for you than for someone who is just starting. You already know how to do this. What we are going to learn together is how to do it in a different place, with people who do not know you yet.)

Graciela is sitting beside Marisol. She has heard all of this. She has not been excluded.

She has watched the nurse talk to her daughter the way she has been hoping someone would.

When Diego pauses: naming the limit without naming the failure

The version of this session where the nurse notices Diego pause is not a different session. It is the same session, with a nurse who looked up before she finished charting.

She sees Diego looking at the phrase and then looking at his grandmother and then looking at the nurse.

She puts the chart down.

“Diego — gracias por tu ayuda. Creo que algunas de las palabras que estamos usando hoy son difíciles de traducir. Son difíciles incluso para los adultos. No tienes que seguir con esta parte. Vamos a buscar a alguien que pueda ayudar con esta conversación — alguien que trabaja con el hospital y cuyo trabajo es exactamente este. ¿Está bien?”

(Diego — thank you for your help. I think some of the words we are using today are hard to translate. They are hard even for adults. You do not have to continue with this part. We are going to find someone who can help with this conversation — someone who works with the hospital and whose job is exactly this. Is that okay?)

Diego says okay.

The nurse does not ask him to try again with a different phrasing. She does not rephrase “end-stage renal disease” into something that sounds lighter but carries the same weight. She does not make Diego feel that he failed at something he was asked to do.

She tells Abuela Rosa, through Diego, that she is going to arrange for a professional interpreter to be present at the next session so that Rosa can ask all the questions she has and understand the answers fully.

Diego translates this.

He translates it easily.

Abuela Rosa nods. She holds Marisol’s hand on the armrest beside the machine.

The professional interpreter is at the Thursday session. Rosa asks the question about the transplant timeline. The coordinator answers it honestly: the waitlist at fourteen months, the odds of a compatible kidney before the adult program cutoff, what the transition means and what it does not mean.

Rosa cries. The interpreter stays with her. Diego is not there.

That is correct. That was not his to carry.

Marisol at 15 and a half

Six months before the transition is scheduled, the pediatric nephrology team arranges an orientation visit to the adult dialysis unit. The adult team comes to the pediatric unit first to introduce themselves. The attending physician is a woman who graduated from UCLA. The charge nurse has been in dialysis for eighteen years.

They sit down with Marisol and Graciela.

The adult attending asks Marisol how long she has been in the chair.

“Three and a half years,” Marisol says. “I started when I was twelve.”

She says it in English. Her English is stronger than her Spanish now, the way it tends to go for a child who did two years of school from a chair.

The adult attending says: “Then you know more about your machine than most of the residents I work with.”

Marisol says: “Probably.”

She says it without arrogance and without apology. She says it the way someone says it when they have been told, by someone who meant it, that knowing the machine is something that matters.

At the orientation visit to the adult unit, Marisol asks four questions. Two of them are about scheduling. One is about the specific model of machine the adult unit uses compared to the one she knows. One is about whether the adult unit has a quiet section because she studies during sessions and some of the other patients watch television with the sound on.

Graciela watches her daughter ask the questions.

She answers one question herself, at the end, about insurance.

Then she looks at Marisol and says nothing.

She does not need to say anything.

Marisol shakes the adult attending’s hand at the end of the visit. She says, in Spanish, because the attending asked if she spoke Spanish and Marisol said yes:

“Voy a ser enfermera cuando salga de la universidad. Quiero especializarme en nefrológia.”

(I am going to be a nurse when I finish university. I want to specialize in nephrology.)

The attending says: “With three and a half years in the chair, you are already halfway there.”

Marisol is fifteen years and seven months old. She has been on dialysis for three and a half years. She is going to the adult program in five months. There is no kidney yet.

She knows all of this.

She is not at the edge of a dance floor doing arithmetic.

She is asking the attending which section of the unit is quieter, because she has a chemistry exam in two weeks and she is going to study for it during her Monday session.

The nurse who asked her “Marisol — ¿cómo te sientes tú hoy?” at the beginning of three and a half years of sessions is the nurse who helped her believe that her voice in the clinical space was something that mattered.

You do not have to do anything complicated to give a teenager that.

You just have to ask her before you ask her mother.