Trying Not to Judge :: N30020 Clinical Journal Entry #18

So Friday was yet another day of our pediatric clinical, and we finally got to move to the "little kids" unit.  I liked the "big kids" unit, but as  you'll know from my stories, I have not been having the best experiences there.  I was welcoming the new unit because of the larger number of beds and change of scenery.  It felt a little weird leaving the nurses and techs that we had finally really gotten to know (on the other unit), but the new unit also meant that peds is almost over (already?!) so no one was complaining!  (1 rotation closer to RN!)

Nicole (Jonathan's sister) had the stomach flu so I stayed at my house Thursday night instead of hers like I usually do since she lives closer to my clinical site.  I was a little nervous about how bad the drive would be from my house, but surprisingly enough, I made it without any morning traffic at all.  I'm pretty much convinced that nurses miss morning rush hour because getting in at 7am is earlier than most people work.  Our instructor lets us get there at 7:30, but I aim for around 7:15 so I think I still miss any trace of rush hour.  The worst thing yesterday was that it was pitch black outside, and it was raining - not a drizzle, more like a torrential downpour.  I only hate driving in two conditions, and those are: driving in fresh snow (the kind that makes your tires make that grinding noise) and in dark, heavy rain.  But I eventually made it in probably about an hour, parked in the new massive parking deck, and chanted "6 seashell" to myself the entire way in so this week I wouldn't forget what floor and row my car was parked in.  I learned the other week that playing Marco Polo in a huge parking garage with a car alarm button is not fun!

First news of the morning, our instructor let us know that no longer were the two units separated by age range but now, seeing how we are in H1N1 flu season, level of infection.  And this apparently was now the infectious floor.  By the end of the day, I doubted that to be true since both floors had a few infectious kids (not just H1N1 though... other illnesses as well) and this new unit most definitely had our younger kiddos.  So thankfully, we weren't all in rooms full of communicable diseases.  (And anyways, why would you make the little kids' unit the infectious unit?  Wouldn't you rather chance it with the teenagers and kids with immune systems larger than the few-month-old babies?  Just a thought...)

My patient was C, an almost-2-year-old with "2 infectious abscesses," being the only thing we knew about her.  Umm, great.  I just had a girl with staph on a tiny cut on her foot the other week, and it was b-o-o-o-o-r-r-r-i-n-g.  I went to review C's chart, and it looked like one was lanced in the ER, the other broke open on its own, and both had tested positive for many gram+ bacteria with staph.  Super.  I perused a few notes before going in for vitals and assessment, and it looked like she had been in several times before for these.  There was a note saying the parents had vocalized concern about cleanliness, and there was an order for an infectious disease consult to get to the bottom of their problem and find out how their home/living spaces would be so infested by staph that their baby would keep getting infected cuts.

Eww.

I went to go to the room and a resident stopped me in the hall, "Are you Amanda?"  I have not one, but two name tags that say it... "Yes."  "Great.  Get some formula for your patient." Please?  Definitely not.  I hate bossy barely-doctors who think student nurses and all other nurses are at various levels of stupid.  Most of the doctors aren't like that, but this one definitely was.  I told her I would and went in to ask Mom what they had C on.  I opened the door and about died from the smell of grunge and a whole bunch of possessions that smelled like cigarette smoke.  The lights were off and Mom greeted me, quite agitated.  "Are you serious? They won't leave us alone.  We're just trying to sleep."  I explained how I was coming to get a bottle for C and that I needed vitals and an assessment and then they could rest for as long as they wanted.  That wasn't good enough for her, but it was how things had to be.  2% milk, vitals, and a nearly-impossible-to-get assessment later (in and out of fussing and kicking and swinging her arms any time I touched her... that's always fun) I was done. Since I felt so unwelcome in the dark room in which I was only allowed to whisper, I was pretty glad to get outside.  C seemed, overall, very healthy.  No fever (well, not like I could get an accurate temperature on her, but she felt afebrile to me), no pain, and one sore was healed over while the other had just a tiny amount of sanguineous exudate, to which I documented with pride, mostly astonished I could remember that word from 2 years ago.  I charted and filled the RN in on my findings.  We discussed C and her family, and she informed me how she expected them to be discharged by noon.  I feared another boring day.

I walked down the hall to see what my friends were up to.  M had a little guy, 7 months old, named D.  He'd been in the hospital for two entire months and had no parents to speak of.  The nurses said Mom has only come a couple of times, and when she does, she's high.  Dad has only come a few times as well, and he apparently just sits on the couch in the room and text messages in the dark.  Maybe tiny D was better off without them.  At any given minute, he had a handful of nurses in his room playing with him, talking to him, or helping him develop with various visually-stimulating toys.  He'd been there so long, they were the only family he had who actually loved him enough to are about his well-being and growth.  D was hooked up to every tube imaginable - IV, central line, catheter, NG tube... probably another one or two I'm missing... and he had just come out of surgery the day before to reverse an ostomy.  Developmentally, he's spending some of the most vital months of his life in the hospital, and who knows how much longer he'll stay.  When and if he leaves, will he go home with his parents?  What kind of life will they give him?  We all tried not to think about it.  Afterall, D's problems only began in the first place because they let him get dehydrated for too long.  One thing led to another and he ended up in this terrible condition.  His nurse said he was just then starting to look better.  He was the sweetest little guy, and my friend who had him pretty much spent the whole day working on his medications alone.  He had so many going into him, it was pathetic.  Over the course of the day, I helped a lot with him.  I didn't have much else to do and M needed some extra help, so it worked out.  Little D liked to be talked to, and he was so content when I'd gently stroke his forehead.  Plus, he needed someone there to put his pacifier back into his mouth each time he'd spit it out or otherwise, much crying would ensue.  It was so sad how helpless he was.

I walked past C's room again, and the lights were still off.  I decided to fill out my care plan assignment before I went in to check on them again...  Lights still off.  I peeked in, and C smiled at me.  She was in her crib walking around while Mom and Dad were sleeping on the pull-out couch.  I smiled at her and waved, not wanting to turn on a light or make too much noise.  I decided these parents might be better left asleep.  I actually left them that way until I knew it was almost time for them to be discharged.  Between that moment and discharge, there was a little more drama that entailed, but nothing other than what made me think these parents really had no idea what was best for their daughter and sadly, were probably too young to even know what was best for anyone really.  I hoped and prayed they'd even fill her antibiotic prescription - trying hard not to judge - and I made sure to go over the discharge instructions very carefully with extra emphasis on taking the antibiotic for the entire length of treatment and setting up their referral appointment with Infectious Disease.  Mom put on C's dingy pink coat, and I walked them to the doors.  I wished them well and waved at C who seemed to think I was great now that I wasn't taking her blood pressure, palpating her abdomen, or trying to hold a thermometer under her arm.  I wondered if these parents knew the huge responsibility they had.  I wondered if they'd ever realize that they were the only two people in the world who could give C a healthier, happier life.

I walked slowly back to the elevators which I took back to the floor.  I was afraid of whether or not I'd get a new patient.  I hoped so.  And please let it be someone with something good!!  We were waiting on 2 admits, and there were a couple patients on the floor who hadn't been assigned to a student.  My instructor told me to go to lunch and then see what she could come up with.  By the time my 1/2 hour lunch was up, the admits weren't there yet (and no one even knew how long it'd be) so my instructor gave me a 1 year old in for biliary atresia. 

I read A's chart and researched biliary atresia online.  I hadn't read much about it before, and I learned that biliary atresia is a disease that occurs in infancy in which the bile ducts from the liver to the gallbladder block off.  All of the bile accumulates in the liver until it quickly causes enough scarring and damage to inflict cirrhosis and require a transplant.  Baby A had a complicated procedure called a Kasai procedure which can sometimes reverse the condition at least for awhile, but it wasn't successful.  Sadly, after receiving a liver transplant exactly a month ago from a deceased 2 year old donor, A was past mild rejection and into moderate rejection.  You wouldn't know it by looking at her, but A's prognosis wasn't good.  She was active, happy, and smart, albeit again, a little developmentally delayed due to her infancy spent being always sick and often in the hospital.  A side effect of her disease is an increased metabolism which makes it hard for an infant to gain the weight she needs, so she was significantly small for a 12 month old.  The nurse told me how important it was to be persistant on giving her bottles (she took special double-calorie formula) because A's mom just somehow didn't understand how important it was for her to have them as often as she would take them.  I tried to explain it to Mom, but I don't think I got anywhere.  Again, I tried so hard not to judge, and I know we as nurses try not to all the time, but each time I went in or walked by, A's mom was talking on her cell phone, sometimes with A's crib rails down, not even paying attention to her daughter.  Each time I saw that, I'd walk in, raise the crib rail, and sometimes get her to take some more of her bottle.  It seemed Mom watched Jerry Springer all afternoon, and I really think she cared more about "who was the baby's daddy" on the television than what her own daughter was doing right there in the crib. Sometimes you really have to wonder where these people are missing it and what - if anything - you can do to help them understand... 

So I spent the afternoon with my baby, A, with M's baby, D, and with my other friend's baby S.  S, probably about 1.5 years old, had the curliest hair, the biggest smile, and the yellowest, jaundice eyes you'll ever see.  Our little yellow baby had Alagille Syndrome, a genetically dominant disease which she inherited from her mom.  The disease can affect the heart and liver to the point of requiring transplants, and it also can injure kidneys, impact bone development, and harm other systems as well.  It comes with prominent facial features such as an enlarged forehead, and of course the yellow eyes and skin from its effects on the liver.  Baby S came from some type of rehab home with an infection and was waiting to get well enough to go back there.  Mom apparently didn't come in to see S much, possibly because she was busy with other children at home or maybe since she herself was sick with Alagille Syndrome.  Mom, waiting for a liver transplant (as a result of her disease process) was several months pregnant with another baby (who could possibly have Allagile Syndrome as well), and that in itself is extremely dangerous.  My friend who was assigned to S was having trouble finishing her clinical papers since S was so restless and fussy lying in her crib, so I came in to see if I could help.  I quickly found that S just wanted to be loved, but I really think that's the case with all of these kids.  And so, I gathered up all 4 or 5 of her various tubes, maneuvered them out of the way, and sat down with her in the rocking chair.  We watched Baby Einstein as she calmed down in my arms, as I told her - albeit unsurely - that everything was going to be okay.

Friday was a particularly heavy day.

With C, D, and S, I really questioned the idea of judging and wondered at what point does a nurse's thoughts cross that line?  What really makes a parent a good parent, and what determines whether or not parents love their daughter or son?  If parents give their child a dirty home, do they love the child any less?  Does that make them irresponsible, ignorant, or maybe just uneducated?  If parents let their infant get dehydrated, are they bad parents?  It's easy to assume they are, but what if they didn't have money to buy formula?  Are they irresponsible for being too prideful to ask for help?  Or did they ask for help, unsuccessfully?  Should an assumption be made, based upon age and skin color, that the formula money was spent on drugs or alcohol?  When are parents careless to conceive another child when he or she has a high chance of having a fatal disease?  When is a mother foolish to carry a child that might cost her life when she has other children to live for?  It's easy to assume she knew the risks, but what if she didn't?  Or what if religion was what made her decide against contraception?  Or did contraception fail?  Science can fail, just as wise people can make dumb decisions or just as we can label someone as anything we want, only to find out we didn't even begin to know the facts.  So is the mother in question a bad mother for being true to her faith?  When is judging inappropriate?  Is it ever appropriate?  When are the thoughts we think indications gauging neglectful parenting or simply matters of opinions reflecting our own ideals and values? When are our judging thoughts examples of the deductions we have been carefully trained to make, proof of the critical thinking we have been carefully trained to use?  When are we crossing a line, and when are we helping, educating, and influencing?  When are we assuming, and when are we knowing?  What is judging, and what is intuition? 

The older I get, the more life I live, the more I realize that rare are the questions that do have answers.