Confessions of a School Nurse

by Michael Alexander

  ‘You’ve got the biggest nits I’ve ever seen,’ I confessed, and she let out a brief scream of horror.

  ‘They come in different sizes?’

  ‘It seems they do, I’ve never seen such monsters, nor so many,’ I joked, trying to make light of the situation. Tracy let out another gasp, then begged me to get rid of them and not say a word. ‘No one can know. Please don’t tell anyone.’

  I reassured her that head lice were perfectly common in schools and completely harmless. I said I wouldn’t tell anyone, but added that we would have to check her roommate as well as washing all her bedding and clothes. ‘It’s hard to keep something like this quiet, but don’t worry, you’re probably not the first and definitely not the only one.’

  There’s comfort in sharing an affliction, like a common cold or head lice, as long as it’s something harmless. Knowing that you’re not alone in your suffering somehow makes the burden easier … that is, so long as you’re not the one accused of being the source of the outbreak. But judging by how well established the infestation was in Tracy’s hair, it would be fair to assume she was the original source. I of course refrained from telling her.

  The following morning twenty or so girls stormed the health centre, led by their spokeswoman, Anastasia. ‘You have to give us shampoo,’ she declared. She also insisted on being told who the source of the head lice outbreak was. At sixteen years of age, Anastasia was already a princess, not in name, but by her demanding behaviour. When you have someone to blame, it’s easier to accept your condition because it wasn’t you that is dirty or has bad hygiene habits, although the girls didn’t realise cleanliness often has nothing to do with head lice. Despite my pleas that no one was to blame, and explaining that any one of them could be the source of any infestation they wouldn’t relent and would not move until they each received shampoo and combs.

  ‘I’ll need to take a look at your head first,’ I said, but Anastasia insisted that they get shampoo regardless if they had lice or not. ‘No one is leaving until we get some.’ Anastasia was a particularly headstrong student and she stood firm, with her arms crossed, feet apart, refusing to budge. The rest of the group followed her lead and stayed put.

  ‘If you’ll let me take a look, it won’t take long to find out if you’re infected, then I can order some.’ I didn’t have twenty bottles of shampoo, or twenty nit combs, and the local pharmacy would have to put in a special order to get enough, which would take another 24 hours. But Anastasia’s argument was that it didn’t matter if she had them or not, because she wouldn’t feel ‘clean’ until she got treatment and she wanted to be 100 per cent sure. ‘I won’t sleep knowing someone in the dorm has lice,’ she declared.

  I tried to reassure her. ‘Have you been scratching?’ I asked. She said ‘no’ but everyone suddenly began to itch their scalp; I had to resist the urge to scratch my own.

  ‘I bet it’s Tracy,’ said a voice from the back.

  ‘Yeah, she’s not here, she’s always got dirty hair,’ added Anastasia.

  The witch-hunt had begun. I had to put a stop to it before people and reputations got hurt. I asked Anastasia if she kept her hair nice and clean. ‘I shampoo every day. I always have clean hair.’

  ‘Actually, head lice love clean hair.’ There were gasps of shock.

  ‘That isn’t funny,’ replied Anastasia.

  ‘Who’s trying to be funny?’

  Head lice don’t actually wander around in search of clean hair, or think to themselves ‘here’s a nice clean person to infect’, they just find it easier to attach to clean hair, and find it a bit harder to stick to greasy hair.

  ‘Perhaps you are infected, maybe you’re the source.’ I took a step away from Anastasia, and the rest of the girls looked at her as if she’d announced she had leprosy.

  ‘No way, there’s no way I’m the source. I’m not even itching.’

  ‘Then you won’t mind me having a look to make sure.’ She realised she had trapped herself, and to prove she was ‘clean’ she agreed to sit down and let me comb through her hair, while everyone watched.

  She was clean, but none of the other girls wanted to be checked, at least not in such a public forum, and over the day, they trickled in to be seen one by one. There were six more cases picked up, although none as severe as Tracy’s. No one ever found out she was the probable source, and within two weeks everyone was in the clear, and the crisis soon behind them.

  Head lice crop up once or twice every year, although one year, the junior boys’ dorm had a constant stream of cases. It wasn’t until we checked the dorm parents that we discovered the source. They felt incredibly guilty, but it helps people when I tell them that even my children, the sons of a nurse, have had them; my wife doesn’t know I share such details, but it’s too late now.

  Sores

  The nits were forgotten, but they’d be back. They always come back, along with other common bugs, viruses, funguses and bacteria. It can’t be avoided when you’ve got six dorms packed with 50–80 kids, with 2–4 kids per room. It doesn’t help when the kids share everything, from their drinks, lips, and more intimate bits … lots more of which later. Right now I was faced with a new problem, a common one … and something I’d never seen before.

  Rebecca, aka Becks, had what looked like a pimple. As pimples go, it was a healthy specimen. It was a lovely size with a ripe yellow head that was pleading to be squeezed. But it wasn’t where it should be, where everyone can see, in the centre of her face, but on her thigh.

  ‘Should I pop it?’ she asked, and I wanted to say ‘Yes, let me do it’, but that’s the wrong thing to do. Squeezing such delectable treats can make the infection worse, as well as help it spread.

  ‘No,’ I said, and she looked as disappointed as I sounded. ‘Just leave it alone, and it’ll go away in a few days.’

  The next day another pimple had appeared, a close neighbour.

  ‘I told you not to pop it.’ The first pimple was just a yellow crust now, while the second was coming along nicely.

  ‘I didn’t. I bumped it on something,’ she protested. ‘Are you sure it’s a pimple though? I never get pimples.’ Judging by the porcelain smooth skin on her face, no pimple would be brave enough to blemish such perfection, but pimples on the legs could be a random event, or not.

  ‘An infected hair perhaps,’ I suggested and she sighed, a wry smile on her lips. ‘Do you see any hairs on my legs?’

  She didn’t have hairy legs. ‘You don’t even have stubble,’ I remarked, and she sat there shaking her head in sadness at my ignorance. Teenage girls, especially older teenage girls, have perfect skin and non-hairy legs. A bit different from girls in my school days, although that may be a local trait of women from the deep south of New Zealand.

  I digress.

  Two pimples on a thigh is not a crisis, and the bursting of the first could explain the appearance of the second. ‘Leave them alone, wash with soap and water, dry gently, and I’ll see you on Monday.’

  Lots can happen over a weekend, and on Monday morning Becks had a dozen pimples scattered over her left thigh, with two on the right.

  ‘They’re not pimples.’ Rebecca was worried. ‘They keep on spreading. Is it something contagious?’ Simple acne is not contagious, but this was something more. I turned to my colleague Michaela for advice.

  ‘It’s a strange place to get pimples, what do you think it is?’

  She knew straight away what it was. ‘You’ve never seen school sores before?’ she said incredulously. I shook my head. I had seen school sores, but had never actually seen anyone with it in such a place. I’d only ever seen it around the mouth and nose. ‘Although it is an unusual place to get it,’ she added, almost as if in apology.

  School sores, also commonly called impetigo, is a common bacterial skin infection caused by the staphylococcus or streptococcus bacterium. This bacterium is very common and most of us carry it on our skin, but it can get into a cut or break in the skin and cause an infection. It
is very contagious. It can be passed by direct skin-to-skin contact, or sharing towels, and we see it with a lot of children, although often on the face, around the lips. But it’s not an emergency, and I’d never seen it before in the emergency room, or even in a general ward.

  But that’s because these illnesses aren’t usually life threatening, and will rarely make it to the emergency room, and your local GP or even practice nurse can treat. By the time Becks saw Dr Fritz the sores had spread onto her lower back and calves. In this case he prescribed an oral antibiotic over a topical antibiotic cream because he felt the infection more systemic. Within a week the sores were gone.

  The real deal

  Not all rashes, blemishes or spots are created equal. I felt sorry for Diego because he looked worse than I ever had, and that’s quite the accomplishment. I had some pretty serious acne in my adolescence, but Diego’s face broke the record books for the number of spots per square inch of skin; even his pimples had pimples. The worst thing of all was that scars were beginning to form. I wanted to help, and knew of a method which had worked wonders for every patient I’d recommended it to. I never expected my good intentions to go wrong.

  People say spots are ‘harmless’ and ‘just part of being a teenager’, but they’re so much more. Acne has a direct impact on your social life. Teenagers can be so cruel. No matter how beautiful you are on the inside, for the treacherous years, it’s so often what’s on the outside that is what matters first.

  ‘Mum said I’d grow out of it.’ Diego was sitting in my office at my request because I was trying to ascertain what he currently used to treat his skin, but more importantly how he felt about potentially being physically scarred for life. ‘And Dad said I need to stop jerking off so much.’ Diego managed a brief chuckle. ‘But I’ve never had it this bad before.’ His acne had become much worse since moving to boarding school, and he admitted that his parents had not seen him since it had worsened.

  He’d tried various creams and facial washes, plus six months of an antibiotic called minocycline, but nothing really worked. He’d tried cutting out fried foods, junk food, and reluctantly admitted he’d even tried stopping masturbating, but only managed two nights without. He was the first and only teenager I’d met to ever admit going to such lengths. Such an admission told me far more than I needed to know, but did give me an indication of how serious he was about getting rid of his acne.

  I felt good at being able to offer him a cure because it’s not always easy to treat a chronic problem with a simple course of antibiotics. With bigger or more chronic problems we help people get through the acute stages of their illness, we help their asthma settle down or their heart to pump more effectively, but then we send them on their way, to live as best they can with their condition. I felt useful and glad that I would be able to solve his problem, and told him about Roaccutane.

  Roaccutane, aka Isotretinoin, is brutally effective in the war on acne. It’s so powerful that people taking it need to have monthly blood tests to check their liver and cholesterol levels. The course usually runs for about four months, of which the first two are uncomfortable if not downright painful.

  During this time patients can expect their face to dry up, including their tear ducts, nasal and oral mucosa; their face looks almost stretched as the skin becomes parched. They say it’s like their face is peeling off. People taking it have to avoid strong sunlight, and constantly have to apply moisturising lotion to their skin as it can sometimes break down and tear, especially around the mouth. To make matters even worse, patients can expect their acne to get worse within the first month. But every single subject I’ve met has been willing to make the sacrifice.

  Such a vicious treatment needs to be prescribed and monitored by a doctor and it was the prescribing doctor’s responsibility to inform the student what to expect. Dr Fritz focused on explaining the physical effects and if, after hearing how severe they could be, they still wanted to proceed, then treatment began as soon as we received written permission from a parent.

  Diego leapt at the chance to finally get on top of his acne and his parents quickly agreed to the treatment. In their letter of consent, the parents agreed that they knew and understood the risks associated with Roaccutane, but what parent truly knows all the risks? For that matter, what nurse ever knows all the risks either?

  By week two Diego’s acne had become worse, and his parched, stretched skin looked like someone recovering from botched cosmetic surgery, as expected.

  By week four his face was still stretched, although the acne was starting to improve.

  By week six there was a marked improvement; there was still plenty of acne, but it was in full retreat, submerging back into the surrounding flesh, no longer angry or full of pus.

  At eight weeks, another side effect became apparent. The end of term grades were out, and Diego’s had dropped, a lot.

  Students’ grades oscillate up and down all the time, but significant drops, from an A average to a C average, are usually a symptom of something out of balance in the child’s life. It may be due to physical reasons, like being sick, or some external influence. A noticeable drop in grade is often the first indicator of something serious.

  ‘You never told me it causes depression.’ Diego had come to the nurses’ office and accused me of not informing him of the risks associated with Roaccutane. He’d been researching the drug online and had come across the psychological side effects, which neither the doctor nor I had mentioned. A bit of googling led him to an article clearly stating that in rare cases Roaccutane can cause depression or mood changes.

  ‘I don’t have the energy to care,’ Diego told me – such succinct words to describe apathy of the mind – adding ‘and I can’t get out of bed.’ No such thing exists as a teenager that leaps out of bed, bright and cheery, but those first words ‘I don’t have the energy to care’ were worrying. I suggested that maybe he’s just not getting enough sleep, or exercise, or a healthy diet.

  ‘Nothing’s changed, sir. It’s the pills. All I want to do is sleep. I don’t want to go to class. Even my friends keep asking me what’s wrong. They say I’m not my normal self.’

  If you look up any drug online and research its side effects, the list is endless, covering almost all possibilities. I researched the NHS guidelines for Roaccutane and got nearly one hundred side effects, from cataracts and seizures to pancreatitis, the latter of which tends to be life threatening. Regardless, it didn’t stop me feeling guilty, and I told him I was sorry.

  He stopped his treatment, and within a couple of weeks his mood improved, and by the middle of the following term his grades had returned to normal, as had his skin, although the acne didn’t return quite as bad as before.

  ‘I’d rather live with the pimples than be messed up the way that shit made me feel,’ he said to me. ‘I never want to feel that way again.’

  I think it also helped that at this time he’d also found his first serious girlfriend, who could obviously see beneath the surface.

  I’m now more cautious when recommending serious treatments, and while I have seen fantastic results when it’s used properly, I make sure to mention the rare, but possible, psychological effects of Roaccutane as well. Though, perhaps most sadly, the majority of people are happier simply because they look good.

  Parents’ worst nightmare

  Part one: Monique

  Acne, communicable diseases, coughs, colds, rashes, cuts, grazes and bruises make up the bulk of my everyday work, but there are also less common problems. Fortunately these only come up once or twice a year. But once a year is enough, and it’s every parent’s worst nightmare.

  Monique crashed. Lots of kids have a mini meltdown when they start studying International Baccalaureate, an advanced high school diploma that kids can choose to do in their last two years of school. Monique’s problem was that she was only fifteen years old. She was in a class one year ahead of most people her age and naturally found it a little harder to fit in with the older
kids. At least that’s what I thought. Despite being slightly younger for her year, she did have two good friends from her hometown of Houston, so I wasn’t worried overly much.

  ‘I just need to sleep,’ Monique confessed. Every student wants more sleep, it comes with being a teenager, but I was pleased Monique was at least being honest. Between the ages 12–16, most patients generally feel the need to justify coming to see the nurse, and will make up a whole barrage of symptoms to get excused from class. I appreciate honesty, and so I let Monique rest.

  Monique was not a regular visitor to the health centre, but I saw her again the next day. ‘I slept the whole night, but I still feel so tired,’ Monique explained. ‘And I feel a bit sick as well.’ Yesterday I hadn’t actually assessed her, as she wasn’t unwell, and just wanted to rest. But I thought it worth finding out a bit more.

  ‘Are you often so tired?’

  ‘I guess so, but it seems worse this last month.’

  ‘What do you mean exactly when you say you feel sick?’ She had felt a bit nauseous for the last few days and put it down to being so exhausted. I checked her blood pressure, pulse and temperature – all normal. I also asked if she had ever had her iron levels checked. She didn’t think so. I asked about her waterworks, bowels, appetite, and diet … I was trying to get as much information as possible to give me some idea of what could be going on.

  It’s not unusual to be unable to find a cause for a particular complaint or symptom, but what I can usually do is eliminate anything more serious. In this case, there was one last thing I had to ask.

  ‘I have to ask a very personal question. There’s no delicate way to put this, so I’ll just say it. Is there any chance you could be pregnant?’

  Monique vehemently denied the possibility. I let her rest for a couple of hours, after which she felt better and went back to class.