Confessions of a School Nurse

by Michael Alexander

  On top of his medical needs, which included everything from managing his diet, recognising a hypo and knowing what to do, the education side of things was a major task, and would affect his future.

  To top it off, he had the worst needle phobia I’d ever seen.

  I informed his mother of these factors, in detail.

  ‘But you’re a nurse, isn’t this part of your job?’ was her response.

  Many parents are not easy to deal with; they don’t always react the way you expect them to, especially when it comes to accepting professional opinions. I try to avoid giving parental advice for a variety of reasons, not least because I don’t always find the right words to express myself.

  Sometimes problems are so unique, so rare, that the right way to handle things is not clear. I’m not sure if that’s a reflection of my own insecurities, or an intrinsic part of school nursing.

  He’s got a life changing diagnosis that he’s going to have to deal with every single day of his life. He needs to be at home, and he needs to be with his family. How could she not understand this?

  I wasn’t getting through to Roman’s mother, and I had to take control of my own emotions because I couldn’t understand why a parent would not want their son at home.

  I didn’t do very well. I had to speak my mind.

  ‘If he were my child, I’d have him at home. He needs his mum and dad. We can manage him here, but we can’t provide the same level of support that you as parents can. We have 400 children here to monitor. My advice is to take your son home.’

  My honesty was greeted with silence.

  ‘I’m sorry, but it’s the truth,’ I was blabbing now to fill the void.

  Finally she spoke. ‘That’s not very professional,’ she said, her voice icy calm. I thought speaking as one parent to another that she would appreciate my straightforward opinion. I felt angry. Surely I’d done the right thing speaking the truth, but Justine, who had been quiet all along, decided to butt in.

  ‘He’s speaking as a parent, not a nurse, I’m sorry …’ Justine began, but I cut her off.

  ‘I’m sorry you’re upset, but no one else is going to say this to you – you need to take your son home. He needs you, he needs his mother.’ My words infuriated her, and she asked me to leave the room while she talked to the other two nurses. To keep the peace I left, but I found myself pleading with her first: ‘My job as a nurse is to give you the whole picture, that’s all I’m trying to do.’

  Was I really just trying to give her the whole picture, or was I judging her? What was my role? Was I a nurse? A parent? I was both, but I’m supposed to be a professional and separate the two. However, when you live and care for the kids in your school, it doesn’t always seem possible to do this. I knew that if Roman stayed at school, he would not get the attention he needed.

  He needed someone, a nurse or a parent, who could be there when problems arose, because here, I’ve got 399 other children to take care of. We could advise him what to eat, but not be there to make sure he ate it, let alone weighed his food. We could remind him to check his sugar before bed, and to have a snack to get him through the night, but we weren’t going to be there to make sure.

  We weren’t going to be there in the night if he woke up confused because his blood sugar was low. We wouldn’t be there to tell him to stay in his bunk bed, while we fetch something sugary. What if he fell from his bunk in a confused state? It wasn’t safe for him at the school.

  I spoke out because we can’t provide what a home can provide. Someone to be there when he needs someone most.

  Roman stayed till the end of the year before changing boarding schools. His blood sugars were a disaster, his understanding of the disease unhealthy, he had more than his share of close calls. We were lucky he made it to the end of the year without serious harm. Sadly Roman couldn’t see this – but what can you expect of a kid who’s had a life changing diagnosis? It’s why I felt so strongly he needed to be at home.

  Roman went to university and he regularly ‘touches base’ with me. He still thanks me for being there during his darkest moments, and tells me ‘you’re one of the good guys’. I’ve never told him about my outburst with his mother. I just ask him what his HBA1C is. This is a blood test that gives an overall indicator of his diabetes control. His reply is usually, ‘could be better’.

  I don’t blame his mother for how things turned out. I don’t blame anyone, although when I relate this story, I still get a little upset that his mother attacked me for suggesting he be taken home. I just can’t understand that.

  It seems I’m regularly overstepping my role, but then that’s what school nurses do when they think they’re doing the best for their patients, when they care so much for them. We want to make sure everyone sees the whole picture, from as broad a perspective as possible. We’ll disagree with the doctor, argue our cause and speak up for those who are too scared to speak up for themselves.

  Gravity

  On average once every two months I’m given a reminder of the nature of gravity, although the speed with which Eva hit the floor was actually faster than the speed of that force.

  To hit the ground as fast as she did, she had to actually throw herself at the ground. To this day, and after twenty years of nursing, I had never seen anyone hit the ground so fast, and with no warning. The odd thing about her landing was that she was lying nicely on her side, with her hair splayed out beautifully around her face, her body conveniently lying in the recovery position. I wasn’t convinced. Her head hadn’t even made a ‘thunk’ when it came in contact with the floor.

  To the average non-medical person, this is a frightening scene. To me, it’s usually nothing to worry about.

  ‘Eva, can you hear me?’ There was no reaction. While I tried to rouse her with my voice, I felt her pulse and looked at her breathing. All were within normal limits. After the verbal stimulation begins the physical stuff, like gently shaking the shoulders, or grasping and squeezing the hand. When this doesn’t work, the normal procedure is to apply increasing levels of pain, to determine to what degree she is actually unconscious.

  I liked Eva, and as I didn’t actually want to hurt her, I did what I always do when I see a suspicious faint. I called out to the other nurses: ‘Can you bring me a needle, I need to test her pain threshold.’ This had the desired result and there was a brief stirring from Eva. Of course she couldn’t wake up straight away, as that wouldn’t look normal, at least in her eyes. If only she knew that nothing about this situation was normal.

  I could have checked her blood pressure, or even her blood sugar, but the needle test is much more effective.

  Michaela handed me a needle. ‘I’m just going to insert it under your fingernail,’ I explained as I took a firm grasp of Eva’s hand. She began to make moaning noises and pulled her hand away before bolting upright. Her ‘symptoms’ magically had disappeared.

  Just for the record, I never use needles when assessing unconsciousness. I do administer pain, as it is allowed, but not in this manner and not in this situation. This was just to let Eva know that I was in charge of the situation.

  It would be a big mistake to assume Eva was just faking it, even though I felt without any doubt she was. The time you decide to assume, without doing a check-up, is the time you get it wrong. Once I had Eva sitting in my office feeling ‘unwell’, I checked her blood pressure, pulse, neurological observations, and even her blood sugar, which were completely normal.

  After half an hour of monitoring, and a note from the health centre excusing her from skiing for the afternoon, she left my office, practically skipping down the corridor.

  Only a handful of students are so dramatic, although it’s this very drama that makes it so suspicious. But that’s just part of the job – giving a teenage girl a credible escape from a bizarre and ultimately exaggerated situation. It always make me wonder – what on earth must be going through their minds in the moments before they decide to faint or pretend to be ill?

/>   Breathless

  I’ve seen it drive some nurses to drink, change placements, or even leave nursing altogether. When you’re at home, and the dribble of a late autumn sun punctured by towering peaks sinks out of sight, and you’re desperate for sleep, the last thing you want is the emergency phone to ring. You never know what you’re going to get, minor or traumatic, harmless or frightening.

  Three nights of my week are spent on call, all afternoon, evening, and through the night. Call-outs can be anything, anytime, anywhere. It’s usually just a kid that’s been sick. ‘I don’t want to catch it!’ I feel like saying to the house parent on the other end of the line. That, or ‘give them a bucket.’

  It’s not the dorm parent’s fault; sometimes they’re new to the job, and new to being a guardian in loco parentis. (The Mexican students told me that ‘loco’ means crazy, which suits me fine.)

  It was late Saturday night and my pyjamas were pulling me to bed when the phone rang.

  ‘Mourad can’t breathe, call an ambulance, he can’t breathe,’ cried Mrs Patton, her voice quivering with panic. I’ve heard this many times, mainly in hospital, where it’s generally been true – out here it usually isn’t. But you never know, and that’s what drives nurses insane. You don’t know what you’re going to find. Luckily, I could hear my patient’s loud breathing in the background. Whatever was wrong, he wasn’t having trouble breathing, quite the opposite. I’d heard this sort of breathing plenty of times before and had a good idea of what was going on.

  I told Mrs Patton I’d be right there, and to not call an ambulance just yet.

  That’s a big call to make. If I was wrong, time would be of the essence, but I felt 99 per cent sure my suspicion would be confirmed.

  I found Mourad in the centre of the dorm, lying on his back on the floor, a crowd of onlookers making him worse. Apart from his rapid breathing, which was at least 100 breaths per minute, his hands were curled inwards, and his eyes were rolling around wildly.

  Mourad was having a panic attack.

  They’re terrifying to watch. The patient barely responds to you, they lie staring at the ceiling, or rolling their eyes back into their skull, sometimes clutching their chest; ‘h … h … hurts’ they manage, or ‘c … c … c … can’t … bre … bre … breathe’. But it’s harmless, self-limiting, and some people say just wait it out.

  ‘He needs to go to hospital.’

  ‘He needs oxygen.’

  ‘It’s his heart, he’s having a heart attack.’

  Crowds never help, so I ordered everyone out the room.

  Mrs Patton leapt into action to gather up the children, but Mohammad, Mourad’s roommate wanted to stay.

  ‘I’m family,’ he said, ‘his dad wants me to stay.’ I had no problem with one person staying, a friend, a family member, although I was worried about his dad being informed already.

  I knelt on the floor, grabbed Mourad’s hand and started to talk, calmly, slowly, reassuring him he’d be fine. He didn’t see me at first, but after a couple of minutes something got through, and his eyes acknowledged me, and his breathing began to slow.

  ‘Can you hear me?’ He managed a nod. ‘I’m going to give you some medicine. Would you like that?’ Another nod.

  For instances like these, we have an agreement with Dr Fritz to give a relaxant, Lorazepam. It’s a benzodiazepine, and they’ve been around a long time, and work very well. I placed the tablet under his tongue and within ten minutes his breathing had slowed even further.

  Thirty minutes later he was breathing normally, lying in his own bed and able to talk. Mohammad was sitting next to him, reading from the Koran.

  ‘He said it helps,’ Mohammad explained. ‘I’ll sit with him all night, it’s not a problem.’ Mohammad was a true friend.

  Another call came in – it was time to talk to Mourad’s father.

  ‘He has to go to hospital.’ His words were not angry, but desperate, a loving father stranded apart, both in distance and worry at this confusing illness.

  ‘He’s going to be fine’ didn’t work, and neither did explaining about a ‘panic attack’. Mourad’s father became insistent.

  ‘How do you know it’s not his heart, he’s never been sick like this.’

  It’s hard to explain that something so dramatic is harmless, but as a nurse I have to do what is right for the patient, not the parent. The worst thing I could do now, at midnight, was to bundle Mourad into a car and take the forty-minute journey to hospital. They’d make him wait. It wouldn’t be deliberate; that’s just the triage system. The nurse would see a sleepy but well boy, not in need of urgent treatment. We could spend hours in the waiting room, that’s what happens on a Saturday night. I told his father all of this.

  ‘He has to go.’ I couldn’t get through his fear. ‘I demand it, he’s my son, and you have to take care of my flesh and blood.’

  I was torn between the father’s agony and what I knew to be in the best interest of my patient. I hoped he would understand in the morning. I said ‘sorry’ as I hung up the phone.

  Mourad woke the next morning as if nothing had happened. He got up, got dressed, and went to breakfast. He spoke to his father, and I took him to see Dr Fritz, who recommended professional counselling. Thankfully, his father was no longer angry at me, and I never was with him.

  Mourad had two more attacks that year, before he was withdrawn from school.

  ‘He’s homesick,’ his father said. ‘He doesn’t like living away from home.’

  And he was probably right in his diagnosis. I suspect Mourad’s problem stopped once he got home.

  I see about a dozen panic attacks each year. They can come out of the blue, but once one’s happened, it’s not unusual for a repeat; it’s why doctors recommend counselling from the very first episode.

  Doing the right thing against a parent’s wishes is frightening as you really have to be sure about your diagnosis and your treatment. Dr Fritz always backs us up, but that’s because we trust each other’s judgment, as well as being comfortable asking questions when we’re unsure.

  Francesca

  My role as a school nurse is sometimes harder than anything I’ve done before. It’s not the isolation, the being on call in the middle of the night for emergencies, or even the vast scope of injuries and illness that I see. Sometimes the hardest thing about this job is trying to keep my charges safe from their own family, especially when money is involved; there are times when people think the more money they spend, the better the outcome, no matter how they behave.

  Take Francesca. Francesca was a petite Sicilian girl who was captain of the volleyball team, the lead actor in several of the school plays, chairman of the school social committee as well as being on the school ski team, and an all-around nice kid. As the years went by, she began to slow down.

  ‘I’ve got so much work to do, I just don’t have the time,’ was her explanation as to why she wasn’t trying out for the upcoming theatre production. She had played a major part in the last three and it had come as a surprise to everyone, especially her drama teacher, but it’s not unusual for students to drop some extra-curricular activities, even when it’s their passion, when they reach their senior year. The workload is impressive and if you want to do well, then like most things in life, you have to focus and sacrifice.

  I didn’t know that she was no longer on the social committee, although if I had, it still wouldn’t have given me reason to be concerned. But when she said she wasn’t going to play volleyball this year I did suggest this was a bad idea. ‘You need to exercise your body, not just your mind,’ I told her, and she managed a smile.

  ‘Heard that line a few dozen times,’ she replied, ‘but I’m just too tired.’ Every single student complains of being tired, so I didn’t find it necessary to find out more this time.

  A few days before the Christmas break I was called to see Francesca in her room. Her roommate, Angela had called the emergency number because Francesca had fallen over getting out
the shower, and wouldn’t get up. I’ve had a few close calls when entering the girls’ dorm, especially in the evening when they’re in various states of undress and have decided to visit their neighbours. I normally get one of the dorm staff to chaperone me, but they were all busy that evening.

  ‘I’m coming in,’ I called out at the entrance to the girls’ dorm, ‘is it safe to?’ ‘Of course it’s safe.’ Angela greeted me in the corridor and led me to her room. ‘Is it safe to come in? Is everyone decent?’ I called out again, before entering the room, ‘the nurse is here.’ Angela opened the door and ushered me inside. Francesca had moved from the floor and was lying in bed, the covers up to her neck, her face pale, her eyes half closed. I sat on the side of her bed to check her pulse, blood pressure, temperature and breathing.

  ‘I didn’t really faint,’ were the first words out of her mouth. ‘I just felt so weak, so tired, I didn’t have the strength to stand. I just sat down.’

  Her blood pressure was a touch on the low side, 95/70, but I wasn’t too worried. A normal adult BP is about 120/80, but in nearly all the teenage girls I see, it’s usually around 100–105/70–80, and Francesca was a very slight young woman.

  ‘I didn’t fall,’ she insisted. ‘I’m just so tired’. Her pulse was fine, and she claimed to be otherwise well, but a healthy young girl should not be collapsing from exhaustion.

  I could think of a dozen reasons she might feel this way; I needed to find out more.

  I began with the usual questions: Did she skip meals? Was she getting enough sleep? Did she stay up late studying? Was she working out at the gym too much?

  She said she didn’t skip meals, she did get enough sleep, didn’t stay up late studying, and had stopped all her sports because she didn’t have the strength, but the pieces of the puzzle fell into place when she said she’d been vegetarian her whole life. Further questioning revealed a very heavy menstrual cycle, as well as a lot of pain.