‘He’s had a bit of a cough,’ Mrs Pierce his dorm parent explained. ‘I didn’t realise he was so sick. He was running around with the others playing football this morning. I’m so sorry.’
The people in charge of the dorms are usually a married couple of any age, but often with their own children, and they’re the heart of all boarding schools, wherever they may be. They act as a parent to these children, hence the title.
Mrs Pierce sounded defensive, but she had no need to be. Kids are renowned for bouncing off the walls one minute, then being deathly sick the next. They reach that tipping point where their reserves are finally exhausted and their body suddenly catches onto the idea that it’s unwell.
With Luke I, at least, had a starting point – a cough and a runny nose. He also had a high temperature, 39.9. I was worried, not because of his illness, but because it was up to me to make the call on what to do. I could make the five-minute drive to the doctor’s office, but Dr Fritz is a busy man. He has a whole village to take care of, and I can’t go running to him every time a child has a high fever. To help me decide, I did what I would do if triaging someone in the emergency room. I got as much data as possible.
No headache, no neck stiffness, no rash and no photophobia (sensitivity to light) plus a probable cause for his fever, that is, a cough and runny nose; probably a simple cold.
Lungs clear, with good air entry on both sides with no wheezes, crackles or signs of respiratory distress and his pulse and blood pressure were fine. But he oozed misery. His body ached and shivered. ‘I’m so cold,’ he mumbled.
It’s normal to feel cold when your temperature is up. Sometimes it’s the first sign you notice when someone is sick; you’ll find them nestled under two duvets with a hot water bottle, trying to warm up, and when you check their temperature, it’s very high.
‘You’re going to stay with us for a bit,’ I explained as I led him through to the sick bay. We have sixteen beds for 400 kids. The most sick get the beds, while the not so sick stay in their dorm where their dorm parent takes care of them. Luke probably had a simple cold, but such a high temperature needed to be monitored.
‘Please don’t take it away!’ Luke screamed, horrified that I’d removed the duvet and replaced it with a thin blanket. It was the most he’d reacted since being admitted. It’s cruel, watching him shiver, and it didn’t help when I placed a cool compress on his forehead. But he was only nine years old and did as told.
Over the next couple of hours, the combination of cooling measures, paracetamol and half a litre of water brought his temperature back down to 37.2, and his actions showed.
‘Can I watch a movie?’ is a sign that a child is getting better. I set him up with something to watch. Once the movie was over, this was followed by ‘I’m bored’. I love those words. They’re almost as good as ‘I’m hungry’. Sure signs of recovery.
All the same, I kept Luke in the health centre that night. Illness comes in waves, and Luke didn’t disappoint. His temperature went up and down, dragging his body along for the ride, but by the following morning he was feeling good again, and after a day with no fever or body aches, he was sent back to his dorm.
Why had I been so worried? Why had I even considered sending him to the doctor? I knew he had a simple cold, and I know that children are adept at taking onboard very high fevers.
It was because I was the one making the ultimate decision, although it did help having two experienced colleagues to turn to. But I was the one making the decisions, especially late at night or on the weekend, and deciding if a fever was benign, or a sign of something more sinister, even life threatening, and I was the one going to sleep at night wondering ‘what if?’. There were no doctors in the background to run a reassuring eye over him, and no blood tests to see how his white blood cells were holding the fort, or inflammatory markers to see how much of a battering his body was taking. I was using my senses and basic observations to make what seemed like a simple call.
But nothing is simple, and in medicine, the simplest decisions don’t happen without a lot of thought. This is my job now. I’m the decision maker, the responsible one. It’s terrifying.
Learning the basics
‘Shit,’ I thought to myself as yet another girl burst into tears. That was three already this morning. What the hell was I doing? Am I some sort of monster?
No, I was just doing what I had done for the last half dozen years – triaging the students as if this were an A&E department.
‘My nose is blocked,’ said Marie. I handed her a box of tissues and moved on to the next patient.
‘I feel dizzy,’ said Sarah. Blood pressure fine, pulse steady and strong, no medical history of note, but skipped breakfast – treated with banana and told to return to class.
‘I’ve got a cough,’ said Isabelle. Chest clear, cough non-productive, dry, had only for 24 hours, no fever, otherwise well, and has not coughed once in the last thirty minutes she’s been in the waiting room – told to take some cough syrup if it comes back, no treatment at present.
Marie hadn’t made it out to the hallway before the flood of tears began again. I stood and watched helplessly as she sat back down between Sarah and Isabelle, who instantly put their arms around her. For teenage girls, tears are contagious, and within moments the three of them were weeping quietly, hands entwined, consoling each other with mumbled words and the occasional glance in my direction, pleading with their eyes for some sign of compassion from me.
I’d never managed to upset three fourteen-year-old girls at once before, but I was doing a fine job of it. I’d even made it an international event, as Marie was Italian, Sarah American, and Isabelle from Russia. I’d covered half the globe.
What the heck should I do?
I did what any male would do when confronted with such a convincing scene. I ran for the hills!
Not really.
I let all three of them rest in the bedroom for an hour and made them some camomile tea with honey.
‘We won’t bother you again all week,’ promised Marie as she went back to class.
‘Thank you so much,’ said Sarah.
‘You didn’t forget to excuse us from class?’ asked Isabelle, making sure they didn’t get an absence marked on the computer.
‘You’re all excused. No need to worry,’ I assured them.
I had just let myself be played. They knew it, and they also knew I knew they knew. I suspect they felt obliged to push the limits. They had three new nurses, completely new to the world of boarding schools, and in these first few months everyone was still figuring out their boundaries. But if I was to continue treating these students like we were in a hospital trauma centre, I was never going to come out on top. I had to come up with another strategy, because if 90 per cent of the patients I had seen this morning had turned up to their local hospital, they would have been encouraged to turn away, or put at the back of the queue and wait hours to be seen.
Hospitals are great for treating accidents and the seriously unwell, but my role as a boarding school nurse was much more than just looking after the sick.
I’m more than a nurse; I’m a parent to these kids, a disciplinarian, an example, a counsellor, a mentor and often a dry shoulder to cry on. It sometimes means playing along with them and their antics, their dramas, and it also means knowing when and how to set limits – you have to know when to say ‘enough is enough’.
One moment I can be reprimanding a kid for bad behaviour, the next I’m consoling a child whose grandfather has just died. Before starting this job I had reasoned that my role would be varied and that I would end up doing things outside my job description. What I was not prepared for was to constantly be playing detective.
In a hospital setting, you tend to believe what the patient tells you. This makes sense as most people don’t like waiting hours to be seen for no reason. But everything’s different in a school, where students are looking for excuses to get out of class or homework.
To avoid b
eing taken advantage of, I began to develop some unique (patent pending) assessment techniques.
‘Sir, I’ve got a sore throat’ was one of the most common complaints. After a quick peek at their throat I could usually tell if they were exaggerating, or outright lying. If it looked OK and they had no fever, I would send them to class with some lozenges and paracetamol. This was never the desired result, and within my second week on the job, the children had become resilient to my tactics.
‘I vomited during the night, and my throat is sore,’ said Marie, the very same Marie who had burst into tears only a week earlier with a blocked nose. Marie had not kept her promise about staying away, she had already become a regular.
Every year there are a dozen or so regulars who stop by two or three times a week, and the reasons vary. They may be homesick, or it may be their first time being unwell without their mother around. Often this changes once they make friends or figure out where they fit in. Sometimes all they need is a wave, a smile, a nod of the head that says ‘I’m here for you’ and ‘you belong’.
The problem with Marie was that she looked in fantastic health. Sure, she could have been up all night vomiting, and one symptom of a bad sore throat (strep throat) is actually an upset stomach so her history does need to be taken seriously as there are potential complications. However, while this is plausible, generally if the throat looks fine, and they have no fever, then I’m stuck with a healthy looking student, with a normal looking throat, who simply claims they’ve been up most of the night vomiting.
‘Your throat is probably sore because of so much vomiting,’ I tentatively suggested, ‘and your throat actually looks fine, you’re not pale, and your tummy doesn’t seem to be making too much noise …’ My voice trailed off as Marie looked ready to shed some tears, but I completed the ritual: 750mg paracetamol (based on her weight), throat lozenges, honey and camomile tea, and a late pass to class.
‘Can’t I rest, for just one class?’ she asked, but her heart was no longer in it. She had won a partial victory with a late pass, my kindness and a detailed explanation of what my examination had found – nothing – and she relented and left, although I did offer her a vomit bowl on the way out, telling her to ‘come back if you fill it up’.
When they don’t get the reaction they want, occasionally a student’s mouth drops open, they pull out their iPhones and dial their parents. Others just head to class. Fortunately, this relationship had moved on from that first teary-eyed encounter, and Marie and I had come to an unacknowledged yet mutual understanding, where she got the full works – medicines, honeyed tea and a late pass – and did not cry or insist on resting in bed. She took the bowl with a sheepish smile. She was ‘well enough’ to appreciate my wry stab at humour.
I’m usually vindicated by lunch break when I see the kids who were supposedly up all night vomiting disregarding my advice about avoiding fried/heavy food, eating fries and hamburgers at lunchtime with no obvious ill effects.
Of course, I did get it wrong sometimes, and continue to do so even now from time to time, but I was adapting. I’d sussed the kids out – who were the ones to keep an eye on – and in turn they were beginning to work me out too.
Agent trouble
‘You will let her rest now,’ demanded Mr Kowski. My finger itched closer to the ‘end call’ button, but I controlled my temper and my ego. Mr Kowski is far from the first, and will definitely not be the last person to have a go at me. The skill is in keeping your voice steady and calm.
Mr Kowski was calling from Moscow and was Irina’s agent.
Irina had just turned fifteen, but was already a regular in the first couple of months of school; at least two to three times a week. As far I could tell she had received great care – the camomile tea, late pass to class, the full check-up of subjective symptoms.
She’d come to the health centre this morning at two minutes to eight, right before the bell for morning class.
Irina claimed she was up all night vomiting, and had not slept, and was having to constantly run to the toilet. But I didn’t believe her.
Why didn’t I believe her?
Everything was normal. Her stomach was quiet, her temperature fine, her pulse and blood pressure normal, her lips and tongue moist, with none of that furry ugliness you normally get when your stomach contents are forced up and out. But people can have normal observations and still be sick. What they don’t do is look so great.
Irina’s eyes weren’t tired, they were lively, and she smelled good, of quality perfume, not the stench of recycled acid and dehydration. She’d also waited until the last minute to see me as well. When you’re that sick, you can’t wait to get someone to help. I find the genuinely sick waiting for me to open the door at seven in the morning still in their pyjamas.
After an examination I had tried to send her to her lessons, with no success. Instead of tears, she chose a more formidable weapon. She pulled out her iPhone.
Irina’s parents were furious, and like many of our students from non-English speaking countries, they had someone else speak on their behalf. Saudi and South American families usually have a secretary, a family friend who takes care of business, while the Eastern European families have agents. They use an intermediary either because their English is not good enough, or because they’re too busy to deal with minor issues like a sick child.
The family secretaries tend to be nice, while the agents are rarely so friendly. ‘I’m paid to be angry,’ one agent even confessed. ‘If a parent shouts at me, then I’m to shout at you.’ But I wasn’t going to ask Mr Kowski if his bravado was just an act.
I’m convinced yelling is a cultural thing. In some places, to yell at those under you, especially if you’re the one paying their salary, is normal, and I’ve even had students admit that if their fathers didn’t yell at their employees, nothing would be done. ‘They expect it,’ they explained.
I told Mr Kowski that, from my medical experience, Irina appeared well. ‘Are you saying she’s lying?’ His tone had quietened, but the threat no less.
‘Yes, she’s lying,’ I wanted to shout. Even good kids try to pull a fast one sometimes.
‘I’m not saying she wasn’t sick. What I am saying is that physically she seems well, and seems to have made a fantastic recovery.’
‘That may be so, but you make her rest, or else.’ Some battles are not worth fighting; they’ll cost you too much.
Irina spent the morning asleep. She had no further vomiting and I did not see her get up once to go to the bathroom.
I had to find a better way to get to the truth.
To aid me in my quest for certainty, I developed the PMU test. If a female turns up to the clinic in the morning, claiming she has a sore throat and has been up all night vomiting, but her make-up is immaculate and she looks great, then she has failed the Positive Make-Up test, and I am less likely to believe her. Obviously, this test is only applicable to girls.
Take Sara. Sara couldn’t see: ‘Sir, my eyes, everything is blurry,’ she insisted. She actually reached down, feeling for the chair behind her. This was one of the more unusual presentations, but I wasn’t concerned. She’d not only navigated her way out of her dorm and into the health centre, but her eye-liner was straight and her mascara not too heavy or too light, but just right. Her eyesight improved dramatically when I volunteered to be her guide and walk her to class. She nearly missed her English test.
Whereas Angela hadn’t slept an ounce. ‘My diarrhoea has been non-stop.’ She limped in with the assistance of her roommate, because that’s what diarrhoea does I guess. Both of them had perfect make-up. Obviously the bathroom didn’t smell bad enough to keep them away from the mirror, but I kept Angela for one hour during which I saw no symptoms. After forgetting to limp around my office, she made her way back to class having missed her PE class.
I can’t remember any patient in my twenty years of nursing putting on make-up after a miserable night spent in the loo emptying the contents of their sto
mach. I’m not talking about a touch of lippy, or a brush with some colour, I’m talking about the sort of make-up you use when preparing to take on the town, the complete works.
This was a breakthrough: a simple positive or negative test, which would help me sort the real from the fakes.
But unfortunately, it was only a matter of weeks before some of the students figured this out.
I’m not sure how they cottoned on to it, although I suspect Irina was the first to make the connections. A month after my run in with her agent, Irina turned up again with the same stomach problem, but this time without the layers of make-up, no perfume, a nice bedhead of hair, and wearing pyjamas.
Now I was stuck with a healthy looking patient, with no symptoms, no make-up, claiming she had a sore throat and had been up all night vomiting.
‘Who are you?’ I said when I first saw Irina in such a state. Oddly, without her make-up she actually looked healthier and brighter, more natural.
‘Sir, I’m sick, don’t make fun of me.’
It was at this stage that I gave up. If a child is so determined not to go to school, my job is not to figure out what is fact or fiction, but to go by their history. So I let her go to bed, but I made sure she had a bowl to throw up in, and told her I expected to see some vomit, or else.
After nearly ten years looking after school children, I’ve learned to pick the genuine from the not so genuine, but my greatest fear is missing the one child who looks only mildly unwell and sending them on their way with something major. This problem is exacerbated by the fact that on a day when there are activities, such as skiing, hiking or swimming, I can easily see up to fifty kids, all trying to get a medical excuse. Everyone loved such activities in my time, but this generation is different, delicate even.
But back then, I was still finding my feet. I had to rethink my strategy as to how best to manage the children.
Taking the lead
I could no longer just take patients at their word, especially when all their symptoms were so subjective. And I clearly still had a lot to learn.
Confessions of a School Nurse Page 2