"Siete, ocho," says the patient, wincing and holding her shoulder.
"Seven, eight," the interpreter repeats to the nurse, answering a question about how much pain the patient feels, on a scale from one to 10.
The nurse asks the patient whether she has any allergies or if she is taking any medications. The conversation moves quickly, English to Spanish, Spanish to English.
A similar scene is repeated dozens of times a day in the emergency room at MetroWest Medical Center's Framingham Union campus, with the languages including Arabic, Chinese, and Russian.
"I could really see the difference," said the interpreter, Raquel Santander-Nelson, remembering when she arrived at the hospital more than a decade ago. "When I started working here, there was a really small interpreter services."
Now there are four or five interpreters on duty at MetroWest Medical at all times, she said. A decade ago, there were only Spanish interpreters; now Portuguese is the most requested language, reflecting the area's large Brazilian population, said Santander-Nelson, who coordinates the hospital's interpreter services.
As more immigrants to Greater Boston have created a higher demand for medical interpreters, the profession is racing to catch up.
Just 15 or 20 years ago, area hospitals would routinely pull in someone from the housecleaning staff to help the medical staff communicate with a patient, according to Beth Donnelly, spokeswoman for MetroWest Medical Center. It is a potentially dangerous practice when someone's health is on the line, she said.
Around 1998, the medical center, formed by the merger of Leonard Morse Hospital in Natick and Framingham Union, made it hospital policy to use only professional interpreters, she said. Then in 2002, it became a state law to use only professionals in emergency rooms and mental health departments.
Now a Boston-based group, the International Medical Interpreters Association, is pushing for a national certification program.
The idea is to standardize the profession in medicine, which is the fastest-growing of all interpreter fields, according to Izabel Arocha, president of the association.
"There seems to be a really good consensus now nationally that the field would benefit from having a national certification of medical interpreters," she said. "Otherwise, what happens is we end up with bilingual employees who are being used to interpret that aren't qualified."
Access to heathcare is a major issue nationwide, and language can be a huge barrier to getting quality care, Arocha said, even when it appears there is help available. An unqualified interpreter can do just as much damage as no interpreter, she said, adding: "An interpreter can make a life-or-death difference."
Demand for medical interpreters is greater than supply, she said, but it's important that people who are bilingual receive the specialized training they need to deal with medical situations.
To address the issue, her 1,500-member nonprofit organization is developing a written and oral test. A Spanish version has undergone trials and is being translated into nine other languages, she said, and the hope is that once such a test is accepted by interpreters, it could be incorporated formally into law. Arocha said she would like to see her organization become a certifying body.
Arocha said it is only natural for the effort to come out of Boston, which she described as the "birthplace of the medical interpreting field worldwide." The old Boston City Hospital was the first to provide medical interpreters, she said.
Demand appears to be rising, but record keeping varied from hospital to hospital until recently, when figures started being reported to the state. Anecdotally, it's obvious to those in the field that their specialty is growing fast.
Representatives of Marlborough Hospital's interpreter services department estimate that a decade ago, they saw three to five encounters daily (each encounter being a patient visit requiring translation). The department now handles 30 to 40 encounters per day, according to Melissa Hodgson, a hospital spokeswoman.
Most hospitals in the state use Spanish and Portuguese interpreters more frequently than other languages, according to data from the state Department of Public Health, but a variety of languages pops up in smaller numbers.
Last year, Marlborough Hospital had 45 requests for Gujarati, one of the main languages of India; Framingham recorded 488 sign-language visits; Milford Regional Medical Center needed Arabic translators on 32 occasions; and Newton-Wellesley Hospital saw 57 requests for Russian interpreters.
Boston Medical Center logged the highest volume of calls for interpreter services in the country, at 194,000, last year. This year, the South End successor to Boston City Hospital will probably break 200,000, according to Oscar Arocha, its director of interpreter and guest support services, who is married to Izabel.
A decade ago, Boston Medical Center saw just 35,000 requests a year, he said.
"The more available you make your services - the greater access there is to interpreter services - the more the system gets utilized," Oscar Arocha said.
Massachusetts is at the forefront of medical interpreting for political reasons too, he said. There is more of an emphasis on social services in this state, he said, and an understanding that it actually saves healthcare dollars if a doctor, with the help of an interpreter, can understand what's going on during a patient's first visit.
Local colleges are noticing the demand. Boston University, for example, has been expanding course offerings at its Center for Professional Education and now offers programs for translating between English and Chinese, Portuguese, Spanish, or Vietnamese.
In Framingham, Santander-Nelson said she looks for job applicants with experience in the medical profession, and she tests them on medical terminology. If they are hired as interpreters, the hospital provides in-house training.
Santander-Nelson, who is from Chile, said she supports the move toward a national certification, and noted that it's not just words, but ideas and perceptions that must be translated.
For example, in some Latin American countries, including Chile, doctors would never tell a patient they are dying, she said. They would tell the family and the family would decide how to proceed. Here, the patient has the right to know everything.
"We are cultural brokers as well," she said.
Santander-Nelson has also played the role of referee. Once, a doctor was upset when a patient was found to be taking medicine obtained from a friend, a common practice in some countries. The patient didn't understand the doctor's reaction. It was Santander-Nelson's job to bridge the cultures.
"It's a very rewarding profession," she said. "There isn't a day that goes by where you don't say, 'I helped someone.' "
Lisa Kocian can be reached at 508-820-4231 or firstname.lastname@example.org.