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…

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??             

Fear/Children and ER nursing

I watched him pace the back wall of the emergency room, cry, kick and scream while he watched my every move. “What is behind your back?” he half screamed and asked. The left side of his flushed face was swollen, more swollen than it was 2 days ago.  This was our second encounter and the thought of him thinking I was going to hurt him ripped my heart apart.  When I saw his fear, and heard the question… “What is behind your back?” I was transported to a time when I was a small child, in the hospital and I asked a nurse that same question…she lied to me and said nothing…then she pushed me over and jabbed a needle in my derriere… I have NEVER done that to a child and I never will; I quickly showed him my empty hands and I slowly sat on the stool. 

A dental extraction that ended up infected brought this amazing little boy to me.  Our first encounter was 2 days prior…he was a week out of an extraction and his face was swollen and he was in pain.  I started his IV with minimal fanfare and he received pain med, antibiotics and fluid.  I gave him a hand massage for 10 min and he fell asleep~~ mom was happy.  He was discharged with a plan…all went well. 

This encounter was after another visit to the oral surgeon, a second extraction and debridement and 2 nights of no sleep, minimal oral intake and a now terrified little man. Mom asked for me and I was so happy that I was on.  She hugged me, he screamed and ran to the back wall….I didn’t take it personally of course but it broke my heart; the fear in his eyes was intense.  Again, this brought me back to when my then 6 year old son was acting like a caged animal prior to his second ear surgery…the fear he had and how awful it was for him and me!!!

I can proudly say that our ER team did a fabulous job orally medicating him with some versed and lorab~ effectively bringing his anxiety and pain levels WAY down…and then the IV was inserted and antibiotics, pain med and fluids were given and he then was admitted.  Mom was happy~ I felt relieved and pleased~ little man was back to talking to me and letting me near him without fear J

Part of my job as a nurse is to calm and reassure my patient and their family; reassure them of my ability and my concern.  Children create a special challenge as we all know.  I was so happy to head home the night after caring for this little man and know that I did my best job with him and his mom.  My experience came into play and my heart was open to them.  I connected with them and it felt good.  I was happy that I was there for them.  I pray he is 100% better now!!

The gift in room 3.

Standing in the middle of the nurse’s station, I faxed a chart to Spring Harbor for our Psych patient in room 11 and I watched the patient in room 3.  Her twisted body was lying on the stretcher in a semi sitting position. She was covered in a blanket and her feet were hanging out, uncovered.  I chuckled to myself because that is how I lay as well~ I hate my feet covered!  She was talking to her husband~ He was gently rubbing her crooked hand…they noticed me watching and both smiled at me, so I smiled back. 

I finished faxing the chart and then went into room 3.  “So how ya doin in here?” I asked her. 

“Just fine.” She answered with a smile.

“Can I get you anything, or reposition you?”

“I would like to be turned.”

I grabbed our tech Paula to help me and we gently turned and repositioned her to the left side, propping pillows behind her and under her legs and between her knees. I gave her a back rub, applied some lotion and covered her with a warm blanket. She thanked us and then said “I’m so sorry to make so much work for you girls.”

“Please don’t say that…it is our pleasure to help you.” I answered with a smile~ and I meant it.

This woman has MS and it has ravaged her body…she is not old…she fully has her mind and can breathe on her own but she has no use of her body what-so-ever!  This woman touched my heart.  She did not complain once during her 12 hour ER stay before a bed finally opened upstairs to admit her to~ NOT ONCE!!  Beyond that she was kind, gracious and funny. 

After her husband left and my other patients were all settled, I went into her room and sat down.  I wanted to ask her something. “I wanted to tell you that you have touched my heart today~ your positive attitude and gracious nature is rare, esp. because of your situation…have you always been a glass ½ full kind of person?”

She began to cry…I got nervous.  “I’m so sorry; I didn’t mean to make you cry….”

She gathered herself, I got a tissue to wipe her face…“No…you didn’t do anything wrong…thank you for telling me I touched your heart…I never get out of the house for visiting anymore…I rarely get an opportunity to talk to other women and I thought I would never make an impact on anyone ever again…”

I cried…not a full out sob but tears…

We talked further and she told me her story~ 1 grown child who is away in Afghanistan…her husband of 34 years is her high school sweetheart…they live modestly…her husband has a small repair business at home so he can care for her as they cannot afford to hire care…she once sung in the church choir and she misses it terribly…

The reason she says she stays positive, “I have always been a happy person, though I did go through an angry stage when the MS started taking away my outside life…but then Jesus reminded me that He was with me…that I still had a purpose …and my husband is still my best friend…”

Could I be this positive in this situation?  Probably not~ but I would want to be. 

I thanked her for sharing her story with me and she thanked me for asking.  I’ve thought about her so much in the last few days because she has led me to pray, to ask God for more gratitude and to see all situations as gifts for growth…and I thanked Him for giving me the opportunity to spend some time with this woman~ to be present in her moment and for showing me the gift of her attitude.

Reiki and the dementia patient

She kept calling out repeatedly for help, with a loud, shrill, shaky voice.  “HELP, HELP, HELP, HELP….” I could not comfort her or reassure her that she was okay, nor could I get her to stop yelling for help.  The staff was getting weary and the other patients thought we were killing her…that fragile little 98 year old women with dementia in room 8. 

She came to our ER from a nursing home with the complaint of, “she won’t stop yelling for help and this is not her normal behavior.”  We worked her up for altered mental status~ and none of the tests revealed a reason for her behavior change… I tried everything to calm her; I dimmed the lights, I sat and held her hand, I turned the TV on and then off, I repositioned her repeatedly and called her daughter (who was in Florida).  The morning rolled on and she kept yelling.

The ER traffic flow subsided somewhat and an opportunity arose for me to have 15 uninterrupted moments with this women.  I turned off the lights, closed the door, turned on some music and performed Reiki on her.  I started from her head and went to her feet.  At first she didn’t appear to even realize I was there, let alone gently laying my hands on her head.  After approx. 2min she stopped yelling.  I continued.  The room was silent except for the soft music… I watched the monitor~ her pulse went from 112 to 88, her blood pressure went from 160/98 to 142/80 and her respirations went from 32 to 18. 

By the time I reached her pelvis, she was asleep.  She remained asleep for an hour and when she awoke she no longer cried for help.  The ER doc on duty that day was a skeptic of the power of Reiki~ he is no longer a skeptic! I gave report to the Nursing Home and sent her back…happy.

I took Reiki as a nursing elective last summer during my BSN classes…I have used it on many of my co-workers, family and patients.  The immediate relaxation it brings is amazing and powerful.  I do not often have time in the ER to perform Reiki on my patients but what a blessing it was for that elderly woman that day…and my co-workers love the 5min head and shoulder Reiki session at the nurses station!!

As nurses we have so many interventions available to us to relieve pain and suffering…it seems that in the last half of my nursing career the interventions went from physically assisting to chemically assisting~ I LOVE that we are now heading in a direction that allows us to get back to our roots…laying our hands on our patients is “old school” but it is what is lacking in our care today. Reiki, aromatherapy, hand massage, light touch, maybe even an old fashion bed bath and simply sitting and talking/listening to our patients are interventions that are free, and powerful…and according to the surveys on patient satisfaction~ those interventions are what get the most BRAVO’s from the patient.  These interventions allow us to be present with our patients…showing them that we do care about their issue and them.  These interventions also are what bring the most satisfaction to me as I care for my patients…