Confessions of a School Nurse

by Michael Alexander

A week passed and I didn’t see Monique at all, until I got a phone call from the local hospital. Three of our girls were in the local emergency room asking to see a doctor. One of them was Monique.

  Confidentiality is paramount to any medical institution, but what’s even more important is a patient’s ability to pay. If you’re not a European citizen then you pay for your privacy, and when Monique couldn’t provide her insurance details, and had no way to pay for her treatment, the hospital called me.

  ‘I’m so sorry.’ Monique was sobbing over the phone. ‘I just didn’t know where to go. You can’t tell my parents.’ After calming her down I said I’d pick her and her friends up shortly. I really needed to know what was going on, but it had to be done in person, not over the phone, so I met the girls thirty minutes later in the hospital waiting room. Everyone was in tears.

  ‘Please don’t tell my parents, they’ll kill me,’ Monique pleaded as we began the drive back to school. Monique was pregnant, and she was trying to find somewhere she could get an abortion. ‘I’m not going to tell them anything, Monique, not without your permission.’ I did add that I would be talking with the other nurses and the school doctor. This issue was something I would need advice with, just as much as Monique.

  ‘You’re not going to tell my parents?’ Monique was disbelieving until I explained that legally I wasn’t able to.

  ‘But perhaps your parents might surprise you. They might be more supportive than you think.’

  ‘You obviously don’t know who my dad is, do you?’ I shook my head. ‘He’s a minister. He’ll be furious because I’m pregnant, and he’d never forgive me because I tried to get an abortion. My life is over.’ I couldn’t think of anything useful to say, so after dropping the girls off with their dorm head I told Monique to come and see me in the morning after I’d had a chance to talk with the other nurses.

  As a parent I would want to know if my child was pregnant, but ultimately the child needs someone safe to turn to. Monique had already put herself at risk by breaking out of the dorm at night-time. She had managed this by tying bed sheets together and climbing down the balcony from the third floor. This may look easy in the movies, but it’s dangerous, let alone during the night, in winter, with ice and snow around. It could have been fatal.

  I was still struggling with what to do. Normally I would advise the patient to tell her family, but the father’s background certainly complicated things. I turned to my colleagues for advice.

  ‘You’re going to have to tell the parents,’ said Michaela, ‘otherwise this could get very, very messy.’

  Meanwhile, Dr Fritz said we absolutely couldn’t tell her parents, even though she was underage, because the child must have someone she can trust. ‘We’re not just legally bound; a patient’s right to safe, unbiased care is at the core of any doctor’s practice,’ he explained.

  I sometimes struggle with this law, and I can understand how parents get furious about it, but even underage children are legally entitled to confidentiality regarding their sexual health. Dr Fritz summed it up by adding that if children feel they have no one safe to turn to, they can put their life at risk. In this case, Monique and her friends could have died climbing out the window. Or, more worrying still, she could have turned to other, illegal, methods to terminate her pregnancy.

  The other two nurses, the school’s counsellor Cathy and I agreed to have a meeting with Monique. She brought along her closest friend, Alice, for support. ‘I don’t know what to do.’ She was sobbing again. ‘My parents will never forgive me for this.’ She repeated those words, over and over, but when I suggested that there is nothing to forgive, she told me I was ‘dreaming’ and insisted she needed forgiveness. Michaela and Cathy tried to reassure her that there was nothing to forgive, but this only made her angry.

  She needed forgiveness, at least in her mind, from her parents, maybe even from God, but most of all she would need to be able to forgive herself. ‘Your parents might be more supportive than you think,’ I kept suggesting, and she snorted in disgust at my continued ignorance. ‘My dad is a minister. I’m not supposed to have sex outside of marriage. He’ll hate me.’

  ‘Your parents won’t hate you,’ I said, believing that I must be right. ‘They will want to help you, be there for you.’

  The truth is, you never know how a parent will react. All I had to go on was how I’d seen parents react in the hospital when I’d had to call them to say we had their child with us. It didn’t matter if it was due to alcohol, drugs, self-harm, or even attempted home-abortions, the large majority of parents were relieved instead of angry.

  Teenagers think a parent’s anger is proportional to the problem created. A parent gets a little angry at their child who does not do their homework, and gets very angry when they find out their child has been in a fight at school, therefore a parent will be furious if they find out their daughter is pregnant.

  This could be true, but the parents I’ve seen in these circumstances have been surprisingly supportive and relieved that they knew, and the children involved have been genuinely surprised to find their parents reacting in such a positive way. My line of questioning was with the purpose of trying to find out if Monique’s parents were the supportive type, or the angry, yelling, make-the-situation-worse type.

  I explained all this to Monique.

  She asked for some time to think about it.

  We saw her again the following morning. She’d made up her mind.

  ‘I can’t do this on my own,’ she said.

  Michaela was first to offer to be there for her. ‘No matter what you decide, you won’t be alone.’

  Does that mean she doesn’t want to be alone while she has an abortion? Or does that mean she doesn’t want to make this decision alone and wants to tell her parents? I assumed the latter.

  ‘Do you want me to call your mother?’ I suggested. Just because mums are mums, and her daughter may become one, it seemed reasonable to make her the first person to tell.

  ‘Yes, I’d like that. If you speak to her first.’ Monique then began to cry. Michaela put her arms around her.

  ‘It will all work out, it will be OK,’ she crooned, gently stroking her hair as Monique buried her head in her chest.

  Part two: the call

  It doesn’t get easier telling parents difficult news. Although, over time, I’ve developed a script to fall back on. I use the same opening line whatever the incident.

  I’ve tried ‘It’s the hospital calling, we have your …’ which is OK, but it’s not enough because you feel the panic rising already, the ‘oh, no’ or quickened breathing on the other end of the line. There’s too much time to panic. Instead I start with ‘Your daughter is fine, and well, but there is a serious matter I need to talk to you about.’ I repeated those words to Monique’s mother.

  ‘Is she sick? Has there been an accident?’ She was worried, but not panicked. ‘Monique’s fine, she’s with me right now. Healthy and sound,’ I added, my tone surprisingly light.

  She asked what the problem was.

  ‘She’s very upset, and worried about telling you, but she wants to tell you herself.’ I handed the phone to Monique and she burst into another round of tears.

  ‘I’m sorry Mum, so sorry,’ she pleaded. ‘Please don’t hate me.’ I could hear her mother making soothing noises down the phone. ‘Mum, I’m pregnant.’ Michaela and I witnessed the relieved expression on Monique’s face when she finished her call.

  ‘They didn’t yell at me,’ was the first thing she said when the conversation ended. Her mother was flying out to meet her the next day. Monique left school and went home with her mother. She didn’t come back to boarding school, although I do get the occasional message from her. She did have the baby and she seems to be happy, although I have no idea how much choice she had in her decision once she made the call to her parents, but she did make that choice, not me.

  And what about the father of her child? It turned out he was a friend of a school frien
d, whom she’d met during a long weekend in Paris. There were many other students there; at least a couple of dozen staying at the five-star hotel her parents had booked her into. It had its own discotheque and like the rest of Europe, no one was fussy about age of consent. I don’t know if he even knows he is a father, although we did encourage Monique to try and find a way of contacting him. I don’t know that she ever did.

  I learned a lot from my experience with Monique, but it will never be easy to tackle these situations. When all is said and done, we try to make decisions that are in the best interest of the patient. Things are never black and white, and each problem has its own unique solution. My opinion on abortion is irrelevant. I feel I helped Monique make her own decision, the decision that was best for her.

  But I do worry. Often the parents of these children are not supportive, more restrictive, and it makes you wonder. If the children had more supportive and less absent parents would they ever find themselves in such serious situations feeling so alone?

  Type I

  Part one: the phobia

  Roman was one of our regulars. It was his first time living away from home, and as far as fourteen-year-olds go, he was a good kid: quiet, hardworking with straight A grades to match, shy, yet not one to change his ways to suit others or fashion. He reminded me of myself at his age.

  Since joining the school, Roman had dropped by the health centre almost every day just to ‘touch base’, as he called it. Half the time he was after something, usually for a minor problem, such as a scratchy throat or sniffly nose. Most times he left my office with nothing because after exchanging pleasantries, and having a chuckle over some mundane school gossip, he usually forgot what he came for and left content.

  On this occasion, Roman had more than just a scratchy throat or tickly cough. This time Roman had spent the weekend alternating between two places; his bed and the toilet. When he was on the toilet he usually had a bucket between his legs. He was the tenth victim to fall foul of the diarrhoea and vomiting (D&V) bug – or Norovirus, as it has become known – over the last week and he would not be the last.

  Apart from some simple medicines to hopefully ease the symptoms, there’s not a lot you can do to help someone with a nasty case of gastroenteritis. Sometimes the medicines help with the nausea or the abdominal cramps, and sometimes they don’t.

  I’d checked on Roman several times over the weekend.

  ‘Rest, small sips of fluid, and time,’ I kept on reassuring him.

  ‘Nothing helps. You must have something else, anything.’ Roman was pleading for medication, but so far none of them were making much difference. Fortunately by Sunday morning his symptoms had improved, but he was still miserable. By Sunday night his appetite had not returned but he was tolerating fluid fine without having to run to the toilet after every mouthful.

  By Monday morning his diarrhoea, cramps, vomiting and nausea had stopped and he managed some toast without any ill effects, although he still looked pale and parched. I kept him in the health centre to build up his strength and make sure he drank enough.

  By Tuesday he was eating normally, but something didn’t look quite right. ‘Are you sure you’re drinking enough?’ I asked, noting his still dry lips.

  ‘I’m drinking plenty,’ he insisted.

  I asked exactly how much and he insisted he had drunk three litres of water in the last 24 hours. ‘I’m fine, just a bit dry. I can’t afford to miss any more classes or I’m going to get too far behind.’

  I let him go to class.

  ‘We’ve missed you,’ I said when I next saw Roman. It was Friday and I had missed his daily visits.

  ‘Too much work to catch up on,’ he explained.

  ‘You back to normal?’ I asked.

  ‘Pretty much,’ he replied, but I wasn’t convinced. He looked pale and still had dry lips, and I told him so.

  ‘I’m drinking heaps, but I just can’t get enough. I’m constantly thirsty.’ At those words, I became very worried. I asked Roman if I could do a blood test.

  ‘I don’t like needles,’ he replied.

  No one ‘likes’ needles, especially teenagers. During the winter season we give mass flu vaccinations and after receiving parental consent, get permission for about three-quarters of the students; we usually end up injecting about 300 students in the course of a morning. The girls feed off each other with their hysteria (though, for 299 of them the hysteria is part of the show; it’s not a real phobia). As for the boys, they’re not as loud, they try to hide it, but they’re frightened as well.

  ‘On the count of three,’ I usually say and inject them on the count of one. Both boys and girls seem disappointed when the injection is over before they realise it’s been given. The majority of them admit that it didn’t hurt.

  I explained all this to Roman.

  ‘There’s no way you’re coming anywhere near me with a needle,’ Roman insisted. ‘Can’t you do another test? What do you want to look for anyway?’

  I didn’t want to cause unnecessary worry, but I had to stress how important the test was.

  ‘I want to assess your blood sugar.’ Roman had no idea what this meant. ‘I really have to do this test. It’s just a tiny prick on the end of your finger. It won’t hurt.’ A tear slid down Roman’s right cheek and his voice cracked. ‘I can’t take needles, I just can’t. You don’t understand. Can’t you do it another way, please.’ Roman’s arms and legs began to shake slightly, a side effect from the nervous release of adrenaline.

  Without the slightest doubt I knew Roman was that one out of 300 that had a true phobia of needles. I desperately hoped my blood test would allay my fears.

  It took twenty minutes for Roman to prepare himself before we eventually got a blood sample. The result was bad. His blood sugar was very high. Roman had developed diabetes.

  Part two: the outcome

  Diabetes is divided into two main categories, Type I and Type II. Type II is the most common. It develops as a result of lifestyle, such as being overweight, lack of exercise, poor diet and so on. The cells responsible for controlling blood sugar become less responsive, or can’t produce enough insulin. People can improve their condition through improving the above risk factors.

  Type I happens suddenly and can happen to anyone at any time. Your own immune system suddenly decides to attack your own body. For some reason it identifies the cells that are responsible for producing insulin as the enemy, and goes about destroying those cells. It’s the more serious of the two because there is no solution. Type I sufferers need injections of insulin for the rest of their life.

  In both types of diabetes, good control is vital. For Type I diabetes, good control is not only essential for staying alive, if practised from a young age, it can reduce the impacts of the disease in later life.

  The immediate danger is low blood sugar or ‘hypo’, a highly dangerous event as you can lose consciousness and eventually die due to brain damage. High blood sugar can also be dangerous, making your blood turn to acid.

  If you manage to avoid excessive highs and lows, a reasonably well-controlled diabetic can still suffer long-term side effects – even if their blood sugars are only a little high. It may take 10–20 years to see the results, but the effects of slightly raised blood sugar over a long period of time are permanent; damaged blood vessels, poor circulation to the limbs, blindness. It’s not uncommon for Type 1 diabetics to have a lower limb amputated.

  Roman had developed Type I diabetes.

  While I’ve looked after many patients in hospital with both types I and II, Roman was the second person I had ever seen develop the disease from scratch. It was new to me and life changing for Roman, but this wasn’t the time to frighten him with all the details. He was terrified already, and with his genuine phobia of needles, Roman was in for the most difficult time of his young life. Diabetes, hospitals and needles all go hand in hand. It cannot be avoided.

  I can remember the absolute terror on Roman’s face the first day of his
stay in hospital as he grabbed my shirt, pleading, tears coursing down his face. ‘Don’t leave me. Don’t let them do this to me.’ I sat beside him clasping his hand as he begged. ‘You have to stop them, please, there has to be another way.’

  I felt close to tears myself; I wanted nothing more than to stop the needles, the intravenous lines and the infusions, but I needed to stay strong for him.

  ‘I’m sorry’ – I found myself saying that a lot over the next few hours – ‘but there is no other way.’ Roman’s sobs swelled, but he held out his arm. I was relieved when the doctor got the line in first go – it’s not always so easy when the pressure is on, and I felt certain that if he missed, I really would have to restrain Roman. I felt helpless that I couldn’t do more, and it was painful to watch him suffer. I had to hold him, a hold that felt almost like a restraint, while the doctor did what had to be done, to save his life.

  Roman spent one week in hospital before he was discharged. His mother came to stay with him for the next month while he adjusted to his new life.

  After daily meetings with Roman’s mother and daily monitoring of his blood sugars, we had a decision to make; what to do with Roman.

  ‘Can you look after my son?’ his mother asked. Michaela, Justine and I looked at each other, wondering who was going to deal with this loaded question.

  ‘We can look after him,’ Michaela began, ‘but we’re not sure if this is the best environment.’

  ‘You’re all trained nurses,’ countered his mother. This didn’t feel like a meeting. She wanted concrete answers. ‘Can you look after him or not?’

  ‘Well, yes we can, but we can’t watch him 24 hours a day. He’ll be sleeping in a dorm, with other kids and teachers who don’t know about diabetes,’ Michaela said.

  ‘I can’t watch him 24 hours a day either,’ Roman’s mother said. ‘What’s the difference with him being here or at home? I don’t see a problem.’ There was silence.

  I did see a problem. It wasn’t just about supervision, it was about developing good habits that would impact the rest of Roman’s life. What he learned now and what practices he developed to control his blood sugars would determine his life expectancy.