Sunday, June 17, 2012

Behavioral health teen and the ER setting.

I stood in the doorway and watched my 15 y.o. behavioral psych. patient.  She sat cross legged on the stretcher, hands tightly clenched in her lap, head down and eyes closed…rocking back and forth.  A loud, continuous hum escaped through her throat…not a song kind of hum…but a static sound of humming. 
She came to us after being kicked out of her foster home for aggressive behavior and suicidal language and she now is boarding with us until a new home or psych hospital bed opens up for her.  Because of her suicidal language all of her belongings were removed from her and she was in our blue hospital scrubs, on a watch with security and in the behavioral health section.  The areas is small, has a TV, a bathroom and small area to walk around~ no windows. Hour 90 was upon us and she was melting down.  As I watched her, my heart broke.  This child was alone~ her life story is of abuse and neglect~ and now once again she is alone…Life isn’t fair for this child!
Earlier that day I silently prayed for her and I sat and talked with her.  She liked to write and to draw, listen to music and take long walks.  Her two siblings were with another foster family and she hadn’t seen them in over 6 months…and there were no relatives to help them out. She was afraid of where she would end up and wanted to run away.  Her suicidal thoughts continued and she wanted to cut herself.  
After speaking with the other nurses who were on that day we decided that we wanted to buy her some journals, drawing materials and get her some shampoo and conditioner (she has long thick hair and we do not provide shampoo in the ER).  The issue with this choice was that it was in direct opposition to what the ER docs had decided.  They were of the feeling that we shouldn’t pamper her in any way because she would like it too much and just continue to say she was suicidal and stay with us.  I totally disagreed~   this particular patient had a distinct problem and she was a child in need of some compassion, empathy and understanding.   The nurses and I talked with the ER doc who was on that day and he agreed with us that we could provide her with some materials to help her pass the time.
The nurses pitched in and on my lunch break I went to Wal-Mart and bought her some journals, colored pencils and drawing paper, shampoo/conditioner and a fancy pen.  When I presented these things to her she sat there staring at me with her mouth open...  “You and the nurses bought these for me?” 
“yes” I answered.
“I can keep them?” she asked in a confused tone.
“yes you can”
“why did you do this for me?” she asked.
“we wanted you to have an outlet for your pain…we wanted you to know that we cared about your situation.”
She cried.  The security guard teared up and had to turn away…
This patient was with us for a total of 146 hours!!  6 full days!!!  Before going off to a psych hospital and then back to her foster home… During her time with us she drew every security guard a picture and she wrote non- stop in her journals…I was rewarded with a poem about myself that hangs in my locker at work. 
I do not know if our nursing intervention helped her in anyway but I believe that it did.  We showed this child empathy, compassion and caring!  I can only hope that it meant something to her and that she will in her heart know that there are kind adults in the world…

Monday, June 11, 2012

Hand massage and the migraine patient.

        I went to retrieve the 13 year old patient from the busy ER waiting room.  I took her chart and looked around the waiting area.  Amongst the noisy crowd; I saw a young girl, head in hands, lying in her mother’s lap.  I called her name, watching to see if this was the young girl with the complaint of a migraine headache.  Sure enough she briefly lifted her head, grimaced and then closed her eyes.
       I got her a wheelchair and brought her and her mother to room 14.  “I can’t talk right now,” she cried as she tried to lie down.  I assisted her to lie on the stretcher, covered her with a warm blanket, put a cold washcloth on her forehead and turned off the lights.  Mom and I softly whispered.
      “Does she normally get headaches?” I inquired.
      “This has been going on for a year now, we have been to her pediatrician several times and we see a specialist next week. “
       “Do you see a pattern at all?”
       “The first headache she got was 3 days before she started her period and they seem to come every month just before she starts…” mom replied.
         I nodded my head in recognition of awareness and then asked her if anything made the pain better or worse.  “Well ibuprofen and Tylenol seem to help a little but we cannot seem to find anything that gets rid of the pain other than getting her to go to sleep but that is so hard because of the pain and everything makes it worse. Her father and I do not want her to start taking narcotics.”  She sadly replied. 
         Handing off her chart to the PA that was to see her, I then went to start her IV and hang some fluids.  I quietly went into her room and explained to her and her mom the reason for the fluids and then swiftly began the task.  (You know a child is in pain when they just lie there and let you start their IV!)
         As I started her IV my heart was just breaking for this little girl who was in such obvious pain.  She was being so brave and trying so hard not to do anything to make her pain worse, like crying.  Mom asked me to be sure that her daughter would not receive any narcotics… I told her I would talk to the PA but that she would have to relay her concerns as well.  I told mom it was going to be several more minutes before the PA could get in to do his assessment.  I then offered to do a hand massage to my patient and she agreed as did mom. 
           The room was quiet but the sounds from the busy ER swirled through the walls.  I silently prayed for the noise level to diminish and for her pain to ease.  I took her left hand in mine and slowly and gently began to massage her fingers, palm and wrist.  I did this for approx. 10 min.  I then took her right hand and did the same.  I felt her relax and listened to her breath even out.  Mom freshened the cold washcloth.  After 20 min my patient was asleep.  I quietly exited the room and mom followed me. 
            Before I could fully close the door mom hugged me and began to cry.  I waited for her to talk.  “I am speechless! I’ve never been able to get her relax and I think she reacts off of my stress that she is in pain…it makes me frantic.  Thank you so much for taking the time to relax her like that…thank you.”
           “Thank you for being open to treatments that are relaxing and do help with pain…narcotics are not the only answer” I replied.
            Mom went back into the room and I went to the nurse’s station.  I found the PA and told him what had occurred and he gave me the look of ya okay…whatever and then just walked off chart in hand.   I won’t go into detail about what my brain was saying to him…
            This patient received 500ml of saline as she slept for an hour.  The PA examined her and after speaking with mom she was discharged home.  No narcotics were given and she left with no headache.  This experience, along with many others this past year have caused me to question the medical model of care that I have participated in over the last 20+ years… why do we always shove drugs at people first??? Why do we always treat the symptom and not the whole person??
           Even in the busy ER we have a few minutes to try interventions that are more nursing in nature and not so medical.  As I have learned more alternative therapies, I have found that they work…and they allow me to connect in a more relational way with my patient~  isn’t that what we nurses all want??