Internship: The Grand Finale (Week 15)

Friday afternoon marked the end of an amazing, intense and extremely educational internship.  In my final week, I ran the floor all by myself, feeling competent and confident the whole way through.

I had one last shadowing experience this week -- just a few hours, not a whole day -- in the Child Advocacy Center.  This center is housed adjacent to the hospital, and is affiliated with it, but provides services to the specific population of children who have been abused (physical and/or sexual).  There I witnessed two forensic interviews, and the accompanying physical exams.  I can't write about any of what I saw or heard, for obvious reasons.  I found the experience intense, heartbreaking, and eye-opening.  Some of these cases go directly to Advocacy, and some go through the Emergency Department first.  I think that in the course of working in an ED I could handle these cases as they came.  But to see nothing but abuse cases all day, every day, week after week, would soon see me suffering severe compassion fatigue.  This is the one venue I've seen child life in that I can clearly say:  This is not for me.

My last day sailed along smoothly until about an hour before finish, when suddenly I got called for three procedures back to back.  Looking back, it kind of seemed like an impromptu final exam.  My teacher said I handled the intense pace with aplomb -- organized, calm, efficient, and effective.  My final review came back with flying colors, and offered praise so generous and sincere it brought tears to my eyes.

 The coming weeks will see me handing out a lot of resumes and hopefully doing some interviewing.  I won't be posting updates about the job hunt process, but rest assured that once I land a job, you'll be hearing all about it.  Matthew has reaffirmed the generous offer he made when my internship started -- to move if I get a job out of town.  So, please keep our family in your thoughts/prayers as we travel through this next transition period in our lives.  All in all, I feel ready for this transition.  The internship provided me with a strong foundation that will serve me well in whatever child life job I find myself.

Meanwhile, you can expect to see lots of updates to the website with all the pictures I've taken of Malcolm in the last 15 weeks, yet failed to get around to posting.  The coming weeks will also see lots of other "catch up" -- like house projects, mountains of laundry, penpals to write to, etc.  Somewhere in all the work, there will be some lazing about, watching of movies, and maybe a yoga class.  And some Starbucks treats.  

Internship: Reflections Week 14

It's all come together this week, and I feel completely ready.  I ran our floor myself this week, which felt amazing!  What a confidence rush!  I can't really offer a "high and low" for this week -- because I have whole fistfuls of "highs" and not a "low" in sight . . . .  which is a pretty good week, I guess.  Let me share a couple highs . . . .

Therapeutic Activity:

Our floor serves all the kids with cystic fibrosis -- a genetic disease that effects the lungs and pancreas.  CF patients are particularly vulnerable to lung infections, and there are even a whole variety of germs that find CF lungs an especially fun place to settle in.  The net result being that we have extra infection control rules to protect our CF patients.  The two big ones are that all CF patients must wear masks when they leave their rooms, and all CF patients must remain at least 6 feet away from any other CF patients.

Right now, we have several teenagers with CF on our floor.  And, as you know, the most important thing (developmentally speaking) for a teenager is hanging out with other teenagers.  Having CF sucks, drastically reducing your life span (average is now 37 years), and really impairing your quality of life with a regime of daily treatments.  So, teens facing all this have a lot in common, and can really relate . . . from 6 feet away.  At least they can text each other, right?

So, this week, I went "way outside the box" and planned a fairly elaborate therapeutic activity for my teens with CF.  We used a large area in the hospital to stage a human board game.  The large room was the board, and the patients the pieces on  the board.  On their turn, patients would roll the dice to see how many steps they could take.  If they came within 6 feet of another patient, that person had to move backwards, in order to maintain the 6 foot infection control rule.  I gave the patients 6 foot poles to measure distance with.  Patients could earn "bonus cards" on their turn by drawing a card and answering the therapeutic question on it.  Questions addressed lots of issues specific to CF and teens.  If they answered, they got to keep the card, and use it to get extra movement on their turn.  The goal is to move in such a way as to "push" the other players out-of-bounds.

All in all, it was a big hit, and the patients seemed to really enjoy it.  It gave them a chance to talk with other teens about their disease, and things they had in common.  Two kids in particular really hit it off, and ended up spending the rest of the week becoming best buds.  There was some tug-of-war with the infection control rules, but eventually they settled into being "texting buds." At least when the grown-ups were around . . . 

Diagnosis Teaching:

I haven't had a lot of opportunities to practice my skills in diagnosis teaching in the last few weeks, let alone demonstrate them for my teacher.  So, I was quite delighted when the perfect situation fell right into my lap.  I was sitting in the playroom (which adjoins our office) playing with a school-age patient, helping distract her while she waited for her upcoming procedure.  The office door was open, where my teacher was sitting doing paperwork, a lucky hearing-distance from the patient and myself.  While we played, I asked her if she had any questions about her upcoming test.  Turns out that she had quite a few, and soon I had out my teaching doll, and was explaining the purpose of different organs, and showing her how the test worked.  She kept asking questions, so we kept talking, until we worked our way around to her core concern, about a possible surgery she might need, based on the results of her test.  Fortunately, I already knew all the info she was after, so the teaching went pretty smoothly.  And my teacher got to listen to all of it, unobtrusively from her desk, and give me feedback after to help me improve my skills.

Procedure Preparation and Support:

Another big "high" this week, was working with a sweet pre-schooler.  My first interactions with the family were providing play opportunities for him while he was in the hospital for testing.  Mom came to me to ask for help with an upcoming procedure, and I was happy to help.  The procedure involved placing a long tube down the patient's nose, which then had to stay there for 24 hours.  Needless to say, this is an incredibly invasive and uncomfortable procedure under any circumstance.  Now imagine it on a pre-schooler.  He was understandably upset with the insertion, and stayed mad for most of the 24 hours following.  The moment it came out, he snapped right back to his charming, playful self.  Mom was crushed to learn that the doctors wanted a follow up test only a few hours later, that involved more things going into her son's nose.  I was called in again.

"Ciliary brushing," involves putting a very small brush up the nose to take samples from the sinuses.  It's very uncomfortable, but luckily pretty quick.  Neither my teacher, nor I, had ever heard of this procedure before, let alone seen it.  Here comes the "high" for me -- my teacher left it all in my hands, and I handled it on my own.  First I tried the internet medical sites, finding little-to-nothing.  Next, I asked the nurse about it -- she'd never seen it before, but was able to show me the tool that would be used.  It looked like a barbie-sized mascara brush, but on the end of a two foot wire.  To a pre-schooler's eyes, it would look very much like the hated tube that had just come out only a few hours before.  My next stop was chatting with the resident who would do to procedure, who explained how far in it would go, and that it would be quick but painful.

Given the age and developmental stage of the patient, I advocated with the medical team for the procedure to take place in the treatment room.  Keeping the patient's bed and hospital room as a "safe place" empowers coping skills at this age.  If nothing "bad" happens in bed, then it's a safe place to rest, play and sleep.  The team agreed to my request, and set up in the treatment room, as I set off to prepare the patient.

He was happy to play with my distraction-toys, but not much interested in hearing about what was about to happen.  In the end, I chose to keep things very simple, especially considering his age.  I asked him "do you ever brush your teeth?"  Turns out he loved to brush his teeth, and told me all about his toothbrush when I asked.  He was able to tell me that the toothbrush's job was to clean away the food on his teeth.  I told him that the doctor had a special brush, much smaller than a toothbrush, that she would use to brush his nose.  "To clean away the boogers?" he asked.  For a pre-schooler, that was certainly close enough.  He was actually quite charmed with the idea of having his nose brushed.  So charmed, in fact, that I took the time to explain that this was a special way to clean out boogers that only the doctor in the hospital does.  At home, we just use a tissue.

Tune in next week for the exciting conclusion of my 15 week Internship Series!

Internship: Reflections Week 13

Pardon me, while I get a big existential here . . . 

You've spent months waiting for Christmas to arrive, counting down the weeks, then days, always knowing that Christmas was coming.  You know it will be December 25th, you have no doubt.  You go to bed on Christmas Eve, knowing with absolute certainty that when you wake the next day, that it will be Christmas.  So, why is it then, that when morning dawns, there's this profound, deep, abiding wonder . . . .  It's Christmas!

It's not like you didn't know when it was coming.  It's not like you doubted it would get here.  And still, you wake up that morning, and the realization pours over you in warm, tingly waves; your eyes widen, and excitement fills up your smile.  You know.  It's Christmas.  And in that moment, it is more real to you that you would have ever thought possible.  The epiphany of infinite reality for one moment fills your entire being, and all of creation becomes that moment, the moment of knowing.

Wednesday night driving home from work, I had one of those moments.  My existence just suddenly filled up with the infinite certainty of knowing.  Knowing that I would be ready.  When my internship ends in just two more short weeks, I will go out into the world, to find a job, and become a Child Life Specialist.  And I will be ready.  

I never really doubted it.  I have every confidence in myself as a student, and the quality of my internship program.  Even in the shaky, scary moments of the journey, I still believed I would learn what I needed to, and that when I got my first job in the field, I'd be prepared to do it.  But suddenly, Wednesday evening, I felt that glorious, all-encompassing moment, of knowing.  Like the arrival of Christmas morning.  Only, it was the arrival of me.

This week, my teacher handed me the reins, and sat back to watch as I confidently took the lead.  I start each day by checking in with each of the nurses, getting reports on all our patients, finding out which patients will need child life services that day.  Of course, lots of kids on the floor need normalization  --  that is, fun things to do, to keep there hospital experience as normal to their everyday experience as possible.  Popular choices this week included playdoh, crafts, coloring, movies, books, toys, and bubbles.  Especially for the kids on isolation (can't leave their room cuz they have a contagious bug), they need lots to do to keep busy and happy.  Remember that play is a child's work.  Playing is a child's first and primary tool for learning, and coping.  This also why we plan so many activities in the children's hospital, like the jugglers, clowns, bingo, visit from the pet therapy group, musicians, puppet shows, etc.  Also toddler play group, music groups, etc.  We usually have at least 2-3 activities going on each day somewhere in the hospital.  (Volunteer Services plans a lot of these.)

In addition to normalization, I have lots of other things to do each day.  Some kids cope better in the hospital than others.  For those kids that are having a harder time of it, I plan some therapeutic play, to address whatever their issues are.  This week, I focused a lot on helping a teenager find non-verbal ways to express her thoughts.  Developmentally, kids don't have the abstract thought skills to be able to "talk thru" their problems, as an adult might in therapy.  That is why we do it through play.  One patient ended up making a collage of her dream home out of words we cut out from magazines.  Thru this activity, she shared with me a lot of her hopes and dreams, her plans for life, and a lot of insight into the less-pleasant aspects of her here-and-now.

This week, I also had a lot of chances to practice my skills in supporting kids through medical procedures.  It was the week of Picc lines (kinda like the big-brother to an IV) and it seemed like everyone was getting them on our floor!  Wee little babies, who I swaddled and sang to while they got their "poke."  For the little ones (under 12 months) we also you a fabulous product, called "Sweatease" which is sugar-water.  We dip the pacifier in it, and give it to them right before the needlestick, and the the combo of sucrose and sucking minimizes an infant's experience of pain.  Of course, as with every single one of our patients, from infant to 21 year olds, we use the Emla cream on the arm ahead of time, which numbs the skin.  This week was the first time I got to help a teenager thru a Picc line -- and I got to do it twice, once for a boy, and second for a girl.  (With teens, those are very different experiences.)  In most ways, teens are easier to get through a procedure, as they can understand why it needs to happen, and generally seem less anxious about the needlestick.  On the other hand, finding things to distract them can be a lot more challenging.  Playing 20 questions, and talking about cheerleading and Hannah Montana seemed to do the trick, though.

My toughest Picc support this week, though, was a very anxious three year old.  Her parents were very nervous, and she picked right up on it.  Fortunately, Versed takes the edge off for our patients.  (For those unfamiliar, Versed is a medication which helps patients to relax, kinda like a "mellow buzz," occasionally causing patients to see double.   A small percentage of kids react poorly to it, and I've heard staff lovingly refer to these kids as the "angry drunks."  My three year old patient was a delightful drunk.  She decided that my Viewfinder was an excellent distraction, and happily looked at several discs of disney princesses to tune out the medical procedure.  Though she still cried a bit here and there, at one point she broke out into delighted giggles.  "There are two Princess Ariels!  And two dogs!"

For the most part, I was doing everything alone this week, with my teacher occasionally tagging along to watch.  Next week, we hope to focus on my skills in diagnosis teaching, procedural preparation.  On the whole, it was a fabulous week.  I know I've lately forgotten to do "highs and lows" at the end of my weekly reflections.  This is because I don't really have any lows to report!  I had so much fun at work this week.  I'm really coming into my own as a child life specialist, and loving each and every minute of it.  I wake up every morning, smiling, thinking "Today, I'm going to make a difference in the life of a child."

Internship: Reflections Week 12

This week has been about building momentum.  My rotation in Pulmonology really revved up this week, with me trying my hand at procedural preparation and support, getting lots of experience with kids with autism, more opportunities to work with adolescents, getting the patient census, etc.  Today I went out on my own to get report from all the nurses, and this week also saw me handling lots of small tasks on my own -- like introducing child life services to new families, meeting kids, finding out their hobbies and selecting age appropriate toys, as well as figuring out which kids to invite to which activities (ie:  music group, toddler group, and some of the big hospital events like bingo and carnival).  I loved the challenge of working with the autistic kids who joined our floor this week, especially the challenge of matching appropriate toys and activities to their individual needs.

Yesterday, I experienced that wonderful confidence booster:  I had several staff members on our floor come up to me, when I was on my own - not with my teacher! - and ask me for help with some child life needs.  To top that, this morning, I had a parent ask me to help her child who was very scared about going to surgery!  That felt pretty good, and made me feel like part of the Pulmonary team!  

There were two kids, in particular, this week who touched my heart.  They were both the same age, and in the hospital for the first time.  The first was extremely anxious about being in the hospital, and terrified to undergo the procedure we went to prepare her for.  We got her through it, though it took a lot of encouragement and still involved a lot of tears.  Later that day, we helped her decorate a "shadow buddy."  These are blank dolls, that kids can decorate with markers, yarn, etc.  She designed hers to look just like her, and then wrote words coming out of the doll's mouth.  "I can't do this!" she wrote.  (Which is what she kept saying about her procedure.)  Then she crossed it out and wrote, "Oh!  That wasn't so bad."  It was like something straight out of a child life textbook.  The next day, I went back to work with her some more, helping her to perform the same procedure on her doll, complete with real needles.  She seemed to love that activity.  Giving kids a chance to reverse roles, to play out the part of the nurse or doctor, is so therapeutic.  It puts them in control, especially when they get to give the doll a needle, and helps them gain mastery over the whole hospital experience.  As we wrapped up the medical play, she told me that her doll did a great job holding still, and that her doll was scared before it started, but now she wasn't scared at all.

The second was very laid back about the whole hospital experience, but it took me several attempts to get her to come out of her room and join in some hospital activities.  Her nurse came to us, asking for help -- she refused to eat.  So, I took her for a stroll around the hospital - a very very slow stroll, as she wanted to handle her wheelchair all by herself.  She didn't need a wheelchair so much as just thought it was a good time.  We walked around, visiting several playrooms, the garden, the teen room, lobby and gift shop . . .  and somewhere along the way, I got her talking.  In the end, she confided to me that the nurse told her yesterday that as soon as she ate something, she would be allowed to go home.  She didn't want to be discharged, she said, she wanted to stay in the hospital and ride the wheelchair and elevator.  In the end, we struck a compromise -- she agreed to eat half her lunch, and I agreed to take her to the afternoon bingo event before she went home.  It all worked out as planned - she even ate more than half, and won several prizes at bingo.  When it came time to leave, she asked me for a hug, and cheerfully rode the wheelchair down to the car to go home.

All in all, a pretty good week!

Internship: Week 11 Reflections

Week 11 marked my move to the Pulmonology Department.  It was a quiet first week among the "wheezers and sneezers."  Most of the kids on my new floor are either cystic fibrosis patients, or asthma patients.  We're just coming out of flu and RSV season here, so only had a handful of kids with those conditions.  Saw some familiar faces, as many kids head to Pulmonary after leaving the PICU.  (Which makes sense, since our floor helps kids who are having issues with breathing, and many of the kids in intensive care are there cuz they stopped breathing.)

My first impressions of the floor are entirely positive.  It's a much more mellow environment than Hem/Onc and PICU were, so it's interesting to see the contrast.  With only 5 weeks in the unit till the end of my internship, my new teacher has put me on an "accelerated" plan.  Generally speaking, I'll be seeing her demonstrate a skill only once or twice before I'm trying it myself.  It was a fairly quiet week, so I'm only checked off on normalization (aka:  playing with kids) so far, but I did get to see a Picc line prep with a teenage patient.  So next Picc line prep that comes up will likely come to me.

Speaking of my new teacher, I really enjoy working with her.  I like her style as a CLS, and her style as a teacher (which can be two very different things!)  One of the first things I noticed about her, as a teacher, is that she has a very different style teaching a child life student, than she does a child (patient).  One of the most useful tools in teaching young children is repetition.  The means that CLS spend their days working with patients who need to be told the same thing 5 times, in five slightly different ways, to help support their learning.  Naturally, many CLS pick up this habit, and subconsciously apply it to all teaching.  In some ways, it's kind of hilarious to listen to a group of CLS (or any childhood educators, I imagine) sit around and explain something to each other.  They frequently repeat the same information 4 or 5 times in a row!  My new mentor doesn't seem to fall into this habit at all.  She explains something once, then asked if I understand.  If I say "yes," that's it, and we move onto the next thing.  I love that!!!

I feel like the end of the internship is suddenly rushing towards me, much faster than I expected.  I have so much still to learn!  Our Friday afternoon workshop this week was on resume, cover letter and interviewing.  I'll start sending out resumes in the next couple weeks, and could conceivably start a job as a Child Life Specialist as early as the end of April!!  Can you imagine?  No wonder I feel like time is rushing by in the blink of an eye!

I know a few of my readers have asked, and more are wondering  . . . . where will this job be?  Who knows?!  There are no openings here in Atlanta that I know of, so finding a job in Child Life means moving.  We knew that before I started the internship, and aren't terribly fond of Atlanta anyway.  We decided a while ago that we'd never be staying here long term, unless something drastically changed our minds.  Matthew's job is a "post doc" and that means it's pretty informal, including how long it will last.  Matthew told me the night before my internship started that when I finished, he'd pack up our family, and moved where ever I wanted for my job.  He's reiterated that offer again this week, as I've been looking at job listings in child life.

So far, I've found 6 openings in San Diego, which would put us significantly closer to my parents (and Aunt & Uncle, and cousins depending on the time of year).  Two openings in NYC, which would be close to my brother, and reasonable driving distance to Matthew's parents and extended family, and Malcolm's birth family (plus all our friends in Rochester!).  I've seen other positions in Florida, Arizona, Texas, Washington, Connecticut, D.C., Massachusetts, and Ohio.  I ruled a few others out on the basis that they get more snow and cold than upstate NY.  Ugh.

Given the economy, our primary goal is a job.  Any job.  And I'll be grateful to have it.  Provided Matthew can find another post-doc in town where said job would be.  After that, something close to family would be nice.  Given that we have family in Buffalo (Matt's immediate and extended family), Rochester (Malcolm's birth family), and NYC (my brother), something within reasonable driving distance (read 8 hours or less) from there would be nice.  That would leave us only having to fly to see my family in California.  Not bad.  In the 8-hour drive radius, we're aiming for something more southernly, to try to escape the cold and snow as much as possible.  Maybe West Virginia?  But an opening in Maine might be worth the cold and snow, as it would put us close to family (my Aunt, Uncle, and Cousins).  I don't know.  The whole process is so complicated, with so many factors!

What do you think?  (Please, I really am asking your opinion, so respond!)  You can respond in the website by clicking the little link below, labeled "Comment," or you can send me an e-mail.  Looking forward to hearing from you!  

Internship: Week 10 Reflections

Hello.  As some of you may have noticed (and a few even e-mailed me to comment), my usual Friday night post never made it up.  Here it is Wednesday evening, and I'm just now sharing my reflections on week 10 (which was second week of the new rotation).  It was a super short week, with only two and a half days in the PICU.  I spent Tuesday shadowing another Specialist (more on that in a moment) and Friday the interns had the day off.  The other intern and I spent our day off writing term papers, and going to a movie together.  Fun!

Shadowing was really neat!  I spent my shadow day at another hospital in town.  Hugh Spaulding Children's Hospital is located downtown, in a rougher part of town.  The hospital is super small, with only 21 inpatient beds, an Emergency Department, a transfusion clinic for sickle cell patients, and outpatient general pediatric section.  The hospital employs one Child Life Specialist for the whole hospital.  It was quite intriguing to see how a one-specialist arrangement works.  I'll give you a hint -- you need really strong skills in prioritizing and organizing your time.  She was fabulous, and I really enjoyed my day with her.  I learned a lot, too!

Week 10 wrapped up my time in the PICU, and I'll be starting in Pulmonary week 11, with a heavy emphasis on Cystic Fibrosis and Asthma patients.  I'll try to post on time for week 11!

Internship: Second Rotation Begins (Week Nine Reflections)

Hello Pediatric Intensive Care (PICU)!

This week flew by as I oriented to the new hospital, new floor, new mentor . . .  and all new ways of doing things!  I am, once again, a little fish in a big sea.  But with so much sea to see!  Though I doubt this revelation will surprise anyone -- the PICU is a pretty intense floor. Most of our patients come to us through the Emergency Department with either trauma (sudden injury like a car crash) or acute illness (like pneumonia).  In my first week I've seen a lot and learned a ton.  Each day I come home with a list of new diagnosis I've never heard of before.  My task is to learn the basics of each, and be able to describe them in one sentence, that a 5th grader can understand.  For fun, I'm keeping a running list, to see how many there are by the end of the rotation.  Maybe I'll make it a guessing game, with a prize for the winner?  Hmm . . . .  lemme think about that!

Here are a few examples:

"Osteogenisis imperfecta" -- This means that your bones aren't very strong, so they break easily, or sometimes bend.  (Made famous in the movie Unbreakable.)

"Hirschsprungs": -- The nerves in part of your colon don't work right, so it makes it difficult, or even impossible, for you to poop!  The doctors can fix it with surgery.

"Ondine's Curse" -- (yes, someone actually named a children's disease "curse."  Not really sure what they were thinking!)  When you fall asleep, your body forgets how to keep breathing, so you need to be hooked up to a ventilator when you go to bed.

"Subglottic Stenosis" -- The smallest part of your airway is too narrow, making it really hard for you to breath.  This is the one of the most common reasons that babies get a "trach" (a special tube in your throat that you can breath thru.)  Sometimes, the doctors can fix this with surgery.

And many many more.  Some of the things I see are really neat and interesting from a medical and Child Life perspective (like Toxic Shock Syndrom, Duchenne's, and Pelizaeus Merzbacher disease).  But, it's really hard to see a family standing around their intubated child while the doctor explains to them that he will probably die.  On the other hand, to be able to help that family, to provide support to a sibling who is frightened and confused, feels pretty good.

My High:  catching on fast to all the new medical jargon, and learning about all the new diagnosis.

My Low:  The hardest things to deal with have been the kids hit by cars, the suicide attempts, and the shaken babies.  

Internship: Reflections Week Eight

So, this is pretty much the halfway point.  This week I finished my rotation in hematology/oncology, and next week I'll start in the Pediatric Intensive Care Unit (PICU) at the other children's hospital.  So I'll go from really knowing where I'm going and what I'm doing, to once again being a very small fish in a very big sea.  But I'm okay with that.  Just think where I'll be in another two months!

My last week in hem/onc was full of amazing everything.  I functioned mostly solo on the floor, with my mentor only coming along once in a while, mostly to either watch me in action, or to meet families who I'd be transferring to her care.  Yes, that means that there were a small handful of families on our floor who had worked only (or nearly only) with just me!  Saying good-bye to staff and patients was tough.  Being on a chronic floor, I have some kids who've been there nearly as long as I have, and I've built quite a relationship with them.  It's tough leaving, and knowing I won't be there to see them thru the course of their treatment, even though I know they're in good hands.  Thankfully, my mentor has offered to send me  e-mail updates, to let me know how things work out for them.  I even had one family give me a picture with a sweet message written on the back.  I'll miss them!  I was pleasantly surprised by how many hugs I received from nurses, social workers, and chaplains on our floor.  I'll miss them, too!

This week included lots of therapeutic play sessions, some procedural support (I finally got to see stitches!), prepping a teenager for the OR, and one afternoon I even ran the entire floor completely alone -- the rest of the team had a meeting off campus, so I was really and truly on my own!  (Okay, I had a back up specialist on a different floor I could page if I needed help, but I didn't!)

My two big stories from the week I'll save until last, as they are my High and Low.  But before I get to those, I should tell you about my End-of-Rotation-Evaluation.  This is a pretty big deal.  I meet with my mentor and the program coordinator and they give me a 10 page evaluation, covering everything you could think of, and 20 subjects more!  They grade me on each of the competencies (separated by knowledge and skill - think "theory" vs. "practice"), my team membership skills, infection control, hospital policy, timeliness, assignments, preparation, adaptability, etc, etc.  There's WAY too much to list.  Let is suffice to say it's extremely thorough!  All in all, I did pretty well.  Most of knowledge and skills are right on track, exactly where I should be at this stage.  I need more work on my therapeutic interventions (an assessment I completely agree with!).  This skill set really just clicked for me only two weeks ago, so my momentum here is just getting going.  Looking forward to more growth in this area.

I managed to get high marks for my "culturally sensitive care," meaning my ability to work with all kinds of family without being judgmental, and to demonstrate knowledge and consideration for various cultural practices.  I felt pretty pleased to be recognized for this, since it's something I've spent years working on.  I also managed to get high marks from both my mentor and the coordinator for being able to take tough criticism and learn from it.  I really appreciated hearing that feedback, too, as that's been one of the tougher things this rotation.  There have been a few times where one or both of them have given me feedback that was really hard to hear, for one reason or another, and I really struggled with it a few times.  I have been asked to change not only how I do some things, but also how I speak, how I think, and how I feel.  Please, take a moment to really think about what that means, and you'll realize just how hard a thing they asked of me.  So to be told later that I amazed them both with my ability to do this . . . well, I'm glad my efforts were appreciated.  'Cuz they sure as hell weren't easy!

The coordinator, who the interns spend every friday afternoon with, has a teaching style that is very different than anything I've encountered before.  She tends to challenge just about everything we say, pushing us to really question and justify every view we hold, personal and professional, and she's not gentle about it either.  After the first week with her, I ran home crying and miserable, not sure if I could stand to go back.  But then I remembered what she said at orientation about her teaching style, and I remembered thinking to myself that her style was going to push every button I had, and that it would be really hard for me to get past that.  So . . .  after that first meeting with her, I had to make a choice -- either Duck'n'Cover, never sharing my opinions again . . . . or Get Over It.  I chose to get over it.  And I'm really glad I did.  It wasn't easy, but it was worth it.  I learned a ton from her, and now Friday afternoons with her are going to be thing I miss most at my second rotation.

Okay, enough introspection, on to Highs and Lows.  I'll start with my Low, so that we can end on a high note.

My Low:  I had my first bereavement this week.  That's one of those hospital euphemisms that means someone died.  This patient has been on complete life support for a little while, and the family chose to de-escalate care.  That's another one of those hospital euphemisms - it means turning off life support.  Remember a few weeks ago, when I told you about going to that workshop and learning about doing hand-molds?  Well, I put that skill set to work.  We made a mold of the child's hand, and ink prints of hand and foot.  I did the foot, and am grateful to say that I got it right on the first try.  The whole situation was so sad, and hard.  I'm grateful that there is a service we can offer to bring comfort to the family.  I made it through without crying, and in fact was coping pretty well.  Then a helpful staff member told me, "You'll get to do this a lot more during your PICU rotation."  I told her, "I'm not thinking about that this week."

My High:  I have a patient I absolutely adore, who I've been working with for several weeks.  He has refused every single activity I have offered, including over a dozen different therapeutics I planned for him!  Even his family joined in on the running joke, and would ask me what I had brought today for him to say No to.  A successful therapeutic with this patient . . . my seemingly unachievable goal.  Until this week.

He loves cars.  He has about 400 Hotwheels on his hospital bed at any given time.  (And, no, that really is not an exaggeration!)  So I walk in, with a bag hidden behind me, and I say "Hi."

He says "I don't want to."  (Sigh.)

I tell him "you are never going to believe what I found today when I was going thru the toy cupboard."

Him:  Is it a Hotwheel?

Me:  Actually, yes!

And I pull out from my bag a shiny new Hotwheel, with a marker taped to it's back bumper.  His looks at the desecrated Hotwheel, then at me in confusion.  I hand it to him, pulling the cap off the marker, and slide a piece of paper under it.  He starts driving the Hotwheel across the paper, and it leaves a trail of ink behind!  His eyes grow big and round, "Ohmigosh!  Ohmigosh!" he declares, a smile erupting across his face.  He drove that car around for the next five minutes, then set it down.  "I'm done."

I smiled and asked, "do you want another color?"

"Yes!"  (I think this is the first time I have ever heard him say this word.)  I pull from my bag another Hotwheel, with a different colored marker taped to the back.  He drove that one around for a while, then the third one from my bag as well.  After that, I offered him two more Hotwheels, no markers attached, and a paper plate with some paint on it.  The idea being to drive the car thru the paint, then drive it across the paper.  Well, turns out that horrible idea is just about sacrilege.  One does not get Hotwheels dirty!  So, at his prompting, we threw the paint in the garbage and taped markers to those two cars.  Then three more which he sent me to fetch, along with more paper.

Notice the language I use there, please.  "He sent me . . . "  You might be thinking to yourself "it's a fun art activity, creative, but I don't get the therapeutic aspect."  No problem, it's kinda subtle.  One of the biggest challenges that most kids face in the hospital is Loss of Control.  This can not only frustration them, but undermine all their coping skills.  An array of doctors and nurses poke and prod, dictate thier diet, want them to pee in a cup, force them to submit to various treatments and exams . . . it's a lot to cope with.  When I walk into a room, I'm one of the only people that a patient can say No to.  It's a powerful thing.  That's why I didn't mind all the time this patient told me No.  Every time he did, he got something out of it.  He got a little control back.  The car-markers game gave him a lot of control back.  He controls what cars he drives, which markers we tape to it, whether or not cars get driven thru paint, and can "send me to fetch" more cars and paper.  Suddenly, he's in control.

Guess what else?  He's smiling, too.  That's a pretty rare sight.  Turns out that a bit later, when his doc came to do his exam, he didn't mind it a bit.  That afternoon, he followed the nurses instructions, without protest.  That's a pleasant change, too.  Pretty cool, huh?

Internship: Reflections Week Seven

This has been the week of Stepping Up, and Stepping Out!

Stepping Up:  as in "step right up, don't be shy!"  By mid-week I had lost count of the times my mentor sent me out on the floor alone.  I tried my hand at a few new skills, and grew my skills in others.  I'm checked off (meaning I can go out alone) on two more competencies (Procedural/Pre-Op Preparation, and Diagnosis Teaching.)  This makes officially, half my competencies!  Here's a peek at a few things I did this week . . . 

I prepared a very anxious 7 year old for a Picc line placement (this is the "big brother" to an IV -- a very thin tube goes from the elbow, up the vein, to near your heart.  It serves the same purpose as an IV, but lasts a lot longer -- weeks instead of days.)  Once I explained it all to her, in terms appropriate to her age and understanding, I then stayed with her for the procedure, which took about 45 minutes, providing ample and creative distraction.  It took everything from "I Spy" books, to flashing lights, to blowing whistles (to "blow away the pain") to making up silly songs to keep her distracted during the procedure.  Distraction for a procedure like this is very important for children.  An undistracted child often fights the staff, pulls their arm away, tries to escape, throws tantrums, throws up . . . . Even if they hold still, the stress of fear and crying will constrict the veins, making it that much harder to find a vein with the needle, and thread the tube.

I had a major breakthrough in my therapeutics skills.  In some ways, therapeutics are the toughest of the competencies to learn.  Prepping, support, diagnosis teaching . . . these are all pretty straight forward.  But therapeutic interventions come in so many varieties and flavors, that knowing what kind of therapeutic a patient needs, let alone picking out a specific one, can be an overwhelming and daunting task.  This week, my mentor really pushed me to figure this out on my own (always providing a safety net so I didn't screw up a patient's care with a bad choice).  Turns out, that when I have to do it on my own . . . I'm perfectly capable!

For example, I had a nurse ask me for help with a specific patient, citing a need for "help with his coping skills."  Well, that's pretty vague. . . This is only his second hospital stay, so does he need . . . 

* An "environmental familiarization" therapeutic, like a hospital scavenger hunt to get to know all the parts of the hospital?  Or making some wall decorations for his room to make it more "homey"? Or an "all about me" collage for his door to help the staff get to know him?

* Or maybe he's overwhelmed and frightened by all the strange equipment and routines at the hospital?  We could do some therapeutic medical play, and have him use a doctor's kit to perform an exam on his stuffed animal?  Or maybe he'd feel empowered to give the doll an IV?

* Maybe he's confused about why he's here?  Should we do a body-outline drawing and see how he decorates it?  Does he know where his tumor is?

* Maybe he's upset because his hair is falling out?  Should I do something to work on his self-esteem?

* Maybe he needs help with pain management?  Should we do a stress glove?  Or some guided imagery? Or some breathing techniques?

* It could be he's missing his friends from home.  We could make a video to send them, and ask them to do the same.

Well, you get the idea.  I could write another 50 pages and still not hit all the possibilities.  When it comes to choosing a therapeutic activity, there is no right answer.  Heck, there's rarely only one right category!  In the end, I spent some time with him, and discovered that pain management would be a good place to start.  So we put some play-doh into a surgical glove, tied it shut, and then squeezed and squeezed.  By the time we finished, he was completely distracted from his pain, and in a cheerful mood.  We talked about how squeezing the glove helped him cope, and asked his family and nurses to help him to remember to use the stress-glove when he was hurting or sad.  The next morning, I returned with a variety of whistles, and we practiced deep breathing and blowing the whistles, again talking about how these things could help him feel better when he's sad or hurting.

This week, I also had the amazing experience of working with the 3 year old sibling of a bone-marrow-transplant patient.  The 3 year old will be a bone marrow donor for her little sister.  After much planning and thinking, I choose to approach my session with her from a medical play standpoint.  There's no method to meaningfully teach a young three year old about leukemia, bone marrow, and blood cells.  But I could certainly help her to become more familiar and comfortable with the equipment she would encounter when donating her bone marrow.  So we played with a doctor's kit, all real equipment, which she tried out on her mom, and we  practiced drinking from a medicine cup (like she would on donation-day) -- she loved that part! -- and I gave her an anesthesia mask to take home and play with over the next week.  While we played, we talked about her little sister, and why she was in the hospital.  The 3 year old loves being a big sister, and sharing her toys.  So we talked about how her sister's blood was sick.  And that she could share some of her blood to help her sister get better.  That went over pretty well.

So, remember how I said this was a week of "stepping up and stepping out?"  Well, here's the stepping out part  . . .  as in, "stepping outside the usual routine."  I'm nearing the end of my first rotation, and by now have a pretty good feel for what "normal" is for a Child Life Specialist working with a chronic population.  But, of course, not every experience falls in the "normal" category.  This week I met a patient that fell well, well, outside the realm of the "typical" for our floor.  The patient had some challenging behavior patterns.  By that I mean:  in the course of a 10 minute tantrum, my mentor got punched, the nurse got kicked between the legs, and I got bit.  Yes, bit.  (Didn't break skin, thankfully!)  We're all sporting a rainbow of bruises from hits and pinches.  (And no, this was not in response to a painful procedure!)  Later that day, one of the wonderful doctor's on the Pysch staff taught me how to do a "basket hold" which would allow me to control arms and legs without getting bit.  It's really a brilliant move!  That being said -- it is never Child Life's job to hold a patient!  Physically restraining a patient is way, way, way outside of what we do, and very counter-productive to the rapport we're trying to build, and our role as the "safe" person in the hospital.  So, hopefully I'll never need to use the basket-hold on a patient, but sometimes reality hits you in the face (or bites you, or kicks you) and you need to "step out" from your norm.

My high this week:  feeling like I've got a handle on selecting and implementing therapeutics.

My low:  one of my favorite nurses got chewed out by a stressed-out parent.  She didn't deserve it, not in any way-shape-or-form!  The nurse took it really hard.  She's one of the best nurses on the floor, and I'm heartened to see the whole team rallying around her with love and support.

Internship: Reflections Week Six

This was a week of really high Highs, and really low Lows.  Let me warn you upfront -- this post will contain some heavy, sad stuff.  It will also be relatively short -- lots happened this week, but because of HIPPA (privacy) laws, I can only share some general thoughts.  So here it is:  The Good, The Bad, and the Insight.

The Good:  Every Child Life Specialist has their own "style."  I've written about this in weeks past, as I enjoyed the opportunity to shadow other CLS and see their way of doing things.  I've spent the last 5 weeks working to gain a new skill set.  This week, enough of the pieces clicked into place that I am starting to get that first glimpse, that enticing glimmer, of what my style will be.  That tells me that I'm getting skilled enough in the basics of what I'm doing, that I can start to work on how I'm doing it.  That's pretty exciting!

For those at home keeping track:  this week I was "checked off" on introducing services.  That's my second competency I'm cleared to perform on my own without supervision now (the first was Normalization.)  My skills in rapport building are growing daily, with big successes this week working with parents, teens, and kids with delays.  I performed "Medical Play" for the first time -- the patient gets to be the doctor, and I have a giant doll that we give an exam, complete with real needles.  This is a wonderful way to help children become more comfortable in medical settings, and to cope with "needle phobia," which is very normal in kids!

The Bad:  This week, though a combination of speaking with other specialists, and observing families first hand, I realized just how prevalent "non-compliance" is.  Whether it's parents not giving children their medicine at home, or not bringing them in when they're sick, or kids with diabetes not testing their blood sugar and taking their insulin, or kids with Chrone's not following their diet . . .  there are thousands of ways for children and families to fail to follow the medical instructions they are given  . . . .  and a thousand consequences to that choice.  It's one thing when an adult makes an informed choice in disagreement with their doctor's advice . . . it's quite a different matter when kids end up in the hospital, the emergency room, the intensive care unit, because their parents chose for them.  Sometimes those choices make the kids really sick.  Sometimes, it kills them.

This is a whole different kind of grief then I have ever experienced before.  It's grief filled not just with sadness, and loss, but with anger, rage, frustration, and the sick, sick feeling of knowing that it didn't have to be this way.  That it shouldn't be this way.

The Insight:  Here's what it comes down to.  All parents love their children.  They may parent their children very differently then I would, they may make different choices for their children . . . they may make very bad choices, ones that hurt or even kill their child . . . but that doesn't mean they love their kids any less than I love Malcolm.  For me, loving Malcolm means taking him to the doctor when he's sick, and following their instructions.  For other parents, loving their child might mean that they don't take them to the hospital when they know they should, because their child hates being in the hospital and is miserable there.  Whether they're making good or bad (or anywhere in between) decisions, they are making them out of love.  

Every parent loves their child.

Please keep my oncology patients in your thoughts and prayers . . . some of them are hanging on by the thinnest of threads right now.

Internship: Reflections Week Five

So, here it is Sunday evening, and I'm finally getting a chance to sit down at my computer.  This past week was a gold-star-week for me at work!

Monday, my mentor sent me out on the floor alone for the first time.  Just to see a few kids for small things, nothing major, but it felt pretty good to walk down that hall alone, and know that I was ready to go into patients' rooms without supervision.  

This week, I also witnessed a Bone Marrow Harvest!  That was an amazing experience!  I had to wear the special sterile blue scrubs, and had as close a view as anyone could want.  Reading up on it ahead of time, I thought that if anything I saw this rotation would make me squeamish, that this would be it.  For the harvest, they use a giant needle in the hipbone, push thru the bone with brute strength, and suction marrow out.  Repeat again and again and again.  They had two harvesters working at the same time.  It was first thing in the morning, so I skipped breakfast, and watched from the farthest corner . . . . But it didn't phase me in the slightest!  Once I watched the first syringe worth come out, I started inching in a bit.  One of the ladies gave us a running lecture the whole time, explaining everything, and she kept encouraging me to move up as close as I wanted.  I ended up about 3 feet from the patient, as close as I could get without being in the way.  It was amazing!  A couple hours later, I watched the very same bone marrow be given to the recipient (donor's brother).  Amazing!

This week, I did two "preps" all on my own.  The first was an OR prep -- we had a patient heading to surgery for a procedure there, so I had the job of preparing her for the experience.  I had a book full of pictures of things she would see (holding room, doctors in blue scrubs with masks/hats/etc., the mask that she'd get her "sleepy medicine" thru, the recovery room where she'd wake up, etc.  Describing the process to her, I focused on sensory experiences -- what she'd see, hear, smell, and feel.  Beforehand she told me she was really scared to go to surgery.  After my "prep" she appeared calmer, though admitted to still being a little scared.  Which is so very normal . . . I and told her that, too!

My second "prep" was for an NG tube.  Nearly all our kids end up with one at some point -- the chemo just ruins their appetite.  And most of them get mouth/throat sores from the chemo, too.  Prepping a school-aged kiddo for an NG tube is never fun.  The decision was made quick, so he didn't even have much time to get used to the idea before we were in there explaining the process to him.  Getting an NG tube is a pretty crummy procedure -- it's wildly invasive, horribly uncomfortable, and there's no really good way to distract a kiddo while it's happening.  But, at least I could prepare him, so he would understand what was happening.  I started by showing him a picture of the GI track, and reviewing with him why nutrition is important.  I asked if he knew what an NG tube was, and he did not.  So I showed him one, letting him touch and manipulate the tube, talking about how it was very thin, soft and flexible.  I also showed him the actual tube (still in its sterile packaging) that the nurse would use for his procedure.  I explained that the tube would go from his nose to his tummy, and that the nurses could put special nutritious "milk" in the tube, so that he could get his food without having to eat.

We talked about that for a bit, then I showed him the procedure on a doll, gently threading the tube thru the doll's nose.  Seeing it on the doll, I think, is what really helped him to understand.  We talked a lot about what his "jobs" were.  This is one of the best coping techniques for kids -- give them a job to do, and help them do it!  His jobs were to "hold still" and "swallow."  We talked about what would help him to do that, ie: holding Mommy's hand, drinking soda to help swallow, etc.  He wasn't happy to be getting an NG tube, but at least he wasn't going into it frightened and confused.

Let's see, what else . . . I attended a conference on Bereavement, and what Child Life Specialists can do to help patients and siblings facing a loss.  We talked a lot about "legacy building" and the grief process, different therapeutic things we can do with patients and/or siblings to help them grieve.  One of the frequent services child life offers is making molds of a child's hands or feet.  (And yes, we do this with a patient who is dying, and for patients who have all ready passed on.)  Much to my delight the workshop included hands-on practice and mold-making.  (I sooooo don't want to be doing this for the first time when it really matters!  My first attempt at mold making, and I snapped the thumb off getting it out of the mold!)

I spent one whole day shadowing another Child Life Specialist on a different floor.  This was an amazingly fantastic experience.  Her style is very different than my mentor's, as different as Yo-Yo Ma compared to Bruce Springsteen.  Both fantastic and what they do, though they do it in very different ways.  Seeing the same things (procedural prep and support, therapeutic play, etc.) done in very different ways really helped to deepen my understanding of Child Life and the skill set I'm trying to build.

My "high" this week:  On friday morning, I arrived at work early.  Walking past the nurses' station to put my lunch in the fridge, one of the nurses flagged me down, saying "Oh good!  Child Life!  I have a new patient is room such-and-such, and he's getting a port today.  I explained it a bit, but he seemed pretty scared.  Can you go talk to him?"  That felt amazing!!  To be tapped by a nurse, treated as part of the team, valued for the service we offer, and knowing just what to do to help the patient . . . . well, that felt really good.

My "low":  (and I can't believe I'm putting this on the blog . . . .) So, it's said that every intern does something stupid at some point.  This week was my turn.  Remember that NG tube prep I told you about a couple paragraphs back?  Remember how I did an extra good job and even showed him the actual tube his nurse would use?  Yeah, well . . . when I finished my teaching, I scooped up all the supplies, dropped them in my prep kit and put it back in the office.  Next morning at flash rounds, his nurse jokingly asked me how much the kid had paid me to sneak the tube out of the room.  Fortunately, she had a whole store room full of spares, but I was still pretty embarrassed!

That's it for now.  See you next week, for more stories from the life of an Intern.

Internship: Reflections Week Four

Week Four was a whirlwind.  I feel like it ended before it even began.  I had my first shadowing day this week, that might be why.  I chose to shadow in Radiology.  This floor is known for it's very high-paced, procedural focused child life services.  It's mostly out-patient as well, so a very different experience from what I've had so far.  Instead of focusing on rapport building, therapeutic play, etc, in Radiology you have about 5 minutes to prepare a kid you just met for a procedure they've never heard of.  Basic X-rays aren't too bad, but some of the other procedures are pretty invasive:  like a VCUG (child gets a catheter, then we fill the bladder with contrast and take lots of pictures to see if it creeps up out of the bladder towards the kidneys.  Then the kids have to pee, while still lying on the table, and we take more pictures.  So, on top of the painful and invasive catheter in their privates, then they have to pee on command for an audience!  Needless to say, this is tough!)  We also prepped kids for ultrasounds ("jelly on your belly!")  Those were pretty easy. 

Sadly, the day I went to shadow was the slowest day in the history of radiology!  Instead of the usual 30 or so patients the Child Life Specialist would work with, we saw a grand total of 4 kids.  Bummer.  But what can you do, right?

I did a lot of therapeutic play this week.  We made playdough and then filled medical gloves with it to make stress-balls for squeezing.  Making the playdough himself helped boost the patient's self-esteem:  "I made this!" and pounding/squeezing it provided a safe and appropriate outlet for expressing anger and frustration.  The playdough-filled glove was designed for squeezing, but the patient decided to instead use it to trick the doctor into shaking hands with the glove.  Good thing it's a children's hospital.  Hee Hee!

With another patient, we made collage posters for his door: one of things he likes (he cut out a lot of food pictures!) and one of things he didn't like (like getting pokes, aka: needle-sticks).  It was a great way to get to know him, and the posters provide a nice way for other staff to know his likes and dislikes.  It also helped the patient to understand that it is okay to express himself, and say when he doesn't like something -- this was something he'd been very hesitant to do.

I'm starting to feel pretty confident on the floor.  In the morning, the charge nurse gives us "flash rounds" -- just a quick report on each kiddo for Child Life and the school teachers, so we know what's changed over night, new admits, etc.  I can follow just about everything at flash rounds now, and have a good grasp of what questions to ask.  Then I can look at my list of patients, and figure out where the highest needs are, who I should see it what order, and what sort of activities I want to do with each patient.  I still need a lot more practice in the different interventions (like medical play, diagnosis teaching, and procedural prep and support), but I'll get that in the next few weeks.  Hopefully in a few more weeks I'll be running mostly on my own.

I got my first try at charting this week.  For those not in the medical world, this is when I write in a patients file about what I did with them.  The hard part is that the correct method for doing it is so exact and complicated, that it is much like learning a new language.  I handed in my first charting assignment yesterday afternoon -- and it promptly came back to me with more red ink than Iceland's national budget.  I get to re-write them and hand them in next week, in addition to next week's charting assignment.  *sigh*  But, she then said to me: for a first effort, my chart notes were really quite good.  So . . . yay!

My low this week:  I thought watching kids get sick with cancer, sicker with chemo, and then maybe die anyway was going to be the hard part of being in hematology/oncology.  I was so very, very wrong.  That part I was ready for.  Turns out, for me at least, the really hard part is the crappy family situations -- the ones that leave the kids crying not because the chemo makes them sick, not because their pain is out of control . . .  but because the parents haven't come to see them in a week.  Or a thousand other sad, horrible, hurtful things.  I wear my oversized heart on my sleeve, and I want to make it all better for these sad, suffering kids.  I want them to have perfect family situations, where they always feel loved and wanted, always nurtured, always provided for, cared for . . . But you know what?  That's probably what their parents want for them, too.

My high this week:  an "ah ha!" moment during a therapeutic play session, that gave me insight into the patient's mind, and his reluctance to express himself.  It was one of those moments when the pieces just click into place, and you see the hidden picture, and you know what to do about it.  That felt really good.

Internship: Reflections Week Three

This week has been all about deepening the skills that I began learning last week.  My first time taking lead was a simple "introduction of services."  This is when we go into a new patient's room, introduce ourselves, and explain what Child Life is, and what services we offer.  I had the chance to observe that last week on two occasions, so when a new patient arrived this week, my mentor asked me if I'd like to take point.  I felt pretty confident, so I gave it a try.  As I knocked on the door, all the pieces of the puzzle bounced around my head -- the 20 things I needed to remember about what to say, and how to say it.  My little heart raced!  Then I opened the door, made eye contact with the patient . . . .  and "click!"  Suddenly, instead of having 20 frantic pieces scrambling about, all I saw was the picture they made.  I smiled, and said "Hi.  I'm Teresa.  I'm with Child Life.  We're here to help with the fun stuff, and the not so fun stuff."  I chatted with the patient and his parents for a bit, then brought him some toys to play with, as well as setting up a chance to teach him about his hospital procedure.  My mentor gave me the thumbs up afterward, telling me I did really well, and helping me fine tune a few points for next time.

Phew!  Later, I learned that most interns report that the first "intro of services" is often the hardest part of the whole internship.  While I was nervous ahead of time, I felt like it was completely natural the moment I opened that door.  I guess my "biggest challenge" will be elsewhere . . . 

Some big highlights of the week:

I had the opportunity to observe a 4 year old get a lumbar puncture (aka "spinal tap")  Our hospital does these under "conscious sedation," so she mostly slept through it.  It was textbook perfect, both medically, and from a patient coping stand point.  My mentor told me afterward "don't ever expect to see an LP go that easily again."  I told her, "Now I have a benchmark to aim for!"

I also witness two Bone Marrow Transplants (BMT)!  WOW!  Sounds exciting, huh? . . . . .  Turns out, it's a bit anti-climactic.  (Though I was still thrilled to pieces to be there.)  For those not too familiar with it, let me give you the quick run down.  For BMT, you start with a series of rough chemo/radiation to wipe out your own bone marrow.  This leaves you seriously immuno-compromised, because you have no white blood cells to fight off infection anymore.  We have a special BMT unit to help protect the kids.  Each room is "positive pressure" which means that air flows out of the room, but never in, to keep all the germs out of it.  Everything is super super clean, and it's isolated from the rest of the hospital.  So, once your bone marrow is all gone, you get your transplant of new cells.  The new cells are stem cells (undifferentiated blood cells.)  These can come from one of three places:  a donor (usually a sibling, taken from the hip bone), cord blood (from an umbilical cord), or from the patient themselves (removed from the blood through aphoresis ahead of time, then frozen until transplant day.  After the transplant, you hang out for a couple weeks and wait to see if the transplant was successful (that is, the cells graft, and start producing new blood cells.)

Here's the anti-climactic part -- the chemo before hand is really rough.  The weeks following the transplant are brutal -- you're the sickest you'll ever be in the whole process.  But the actual transplant . . . . is barely a blip on the radar.  No surgery, no fuss.  The new cells go into the blood stream (via a central line) either by  syringe, or a hanging bag.  Just like a blood transfusion.  The cells then find their own way to the bone marrow.  Like magic.  I was really surprised.  The whole thing takes about 5 minutes, and it's done in the patient's room.  It takes more time to verify identity (match patient ID band with label on the syringe) that the actual transplant does!  Even so, I was very excited to see it.

Let's see, what other neat things did I get to be a part of?  Oh!  Needle play.  We had a kiddo terrified of needles, and he'll be getting several blood draws in our out-patient clinic in the coming weeks.  So we brought a stuffed doll for him to "play doctor" with.  He played doctor and drew "blood"!  With a real tourniquet, alcohol swap, a real needle, real vials that he filled with pretend blood, and a band aid to finish.  We asked him "what should the doll do when you put the needle in?"  He told the doll "close your eyes, and say your prayers!"  That cracked me up!  After some practice, play, and talking, he decided that the doll wanted to lay down when he got his "poke" and that the doll should close his eyes and count to three.  So we practiced those skills, and talked about how he could do the same thing as the doll when he's at clinic, and it's his turn to get a "poke."  By practicing, and playing it out, especially from the doctor's role, he gained some mastery over the situation; relieved his fears, & practiced his coping skills.

One of the tougher things this week . . . . I've been learning a lot more about the diseases on my floor . . .  many types of cancer and other things that lead to BMT.  The presenting symptoms, the different treatments, chemo drugs, their side effects, and when hospice care is called for (we sent a kiddo home on hospice care today.)  So, my brain is filled will all the stuff I'm learning about cancer, then I go to sleep at night, and my brain reviews the info, playing it over, rehearsing it, and replaying all the cases I'm working with. . . .  With Malcolm in the starring role.

The first night I woke up sobbing, in a cold sweat.  The second night I watched Malcolm get diagnosed, treated, suffer through chemo, and die about 6 times.  The third night I watched him get a BMT, have it fail, then suffer infection after infection till he died miserable, blind and in pain.  That morning I decided to never sleep again.  Ever.

I talked to my mentor about it that day.  That night, before I went to sleep, I reviewed frequency rates of childhood cancer, reminding my brain how very very rare these diseases are.  Just 'cuz we have 30 kids with leukemia on our floor does NOT mean it's common.  It's really really far from it.  Then I review the fantastic survivor and cure rates.  Then I look at pictures of Malcolm happy and playing, and picture him healthy and growing as I fall asleep.  I've now been nightmare-free for three nights running.  My brain is still reviewing all the things I'm learning, in my dreams, helping me to process and learn all the new info.  But Malcolm is, happily, no longer in my dreams!  Soon, I will have mastered most of the relevant medical info for my internship rotation in hematology/oncology, and my brain can move on to review other things in my sleep.  Like the sweet sound of Malcolm's giggle.  (Which, if you haven't heard, you can still enjoy by calling our home when we're not around, and listening to our answering machine.)

That's all for now.  See you next week for more updates!

Internship: Week Two Reflections

Week two was an amazing whirlwind!  It was my first week on the floor.  For those of you following along at home, I'm on the hem/onc floor which means I'm  working with kids with cancer, blood disorders, and bone marrow transplant.  Our floor is sponsored by Aflac, which means we have a ton of resources, including a HUGE Child Life staff.  We have 2 Child Life Specialists (CCLS), and a Child Life Activities Coordinator.  The Activities position does group activities, and can do play at the bedside for kids on isolation, and check in with some of our kids who have less urgent needs.  That leaves the Specialists to focus on the more urgent needs, and high priority stuff.  To put this is perspective, most CCLS serve about 30 kids at a time.  We have about 12-17 kids per Specialist, plus the help of the Activities person.  It's really nice.

On our floor, the kids are split by diagnosis.  So one CCLS gets the kids with blood disorders (like Sickle Cell) and ALL (the kinder, gentler leukemia).  The other (my mentor) gets solid tumor (like brain and bone tumors), AML (the rougher, tougher leukemia), and all the kids getting bone marrow transplants.  

Day one on the floor was an eye opener.  We started with morning report at 8:30 am, in which we met with the charge nurse to get a quick run down on each child.  This was my opportunity to learn how very much I need to learn about the medical side of treating cancer, blood and bone marrow disorders.  I think I understood about 10% of what the nurse said!

At 10:30 am we had a Code Blue.  My mentor later told me this was the second one she'd ever seen in all her years in hem/onc!  For those who don't know, a Code Blue is true medical emergency.  I means that someone is not breathing/heart not beating.  The situation ended happily, the child was fine.  But for about 5 minutes it was pretty scary.  About 6,742 people came running as the alarm went off.  Doctors, nurses, NP, respiration therapist, social work, chaplaincy, child life, security, etc.  It was reassuring to see so many people responding so quickly, calmly, and competently!  I performed my role perfectly, and with out prompting -- I stuck my back up against a wall, and stayed the heck out of the way!  Once the first wave of responders went running by, my mentor and I checked the hallways and surrounding area for any kids/families that might be witnessing the Code and feeling confused or scared.  We didn't find any, but if we did, it would have been our job to help them understand what was happening, and soothing their fears, and helping them to cope and process this frightening event.  The child that coded was assigned to the other CCLS on the team, so she went to the child's room to provide support for siblings and family present in the room.  A few minutes later it was all over, child safe . . . happy ending.

The rest of the week was much quieter by comparison.  My mentor walked me thru the basics of the medical stuff, so by Tuesday morning's report, I was able to understand about 90% of what the nurse said!  Yay!  (Learning that fast was a huge boost to my confidence!)

I had to opportunity to observe two different Diagnosis Teachings.  One of the jobs of the CCLS is to educate patients, in an age appropriate manner, about their diagnosis.  As you can imagine, explaining leukemia to a 4 year old is very different then explaining it to a 16 year old!  The first teaching I observed was for the siblings of a newly diagnosed leukemia patient, helping them to understand their sister's disease, as well as helping them to understand why she's in the hospital, and Mommy is away from home so much to help her.  The second teaching was for also for a sibling, who would be a bone marrow donor for his brother.  My mentor used a giant toy bone, which unzipped, and pulled out felt pieces representing each type of blood cells.  "The red blood cells' job is to bring energy to all the parts of your body.  The white cells are your solider cells, they fight off infections!  These are called platelets, and they are like band-aids.  And these cells are cancer cells.  They don't have a job.  They make your blood sick."

This week, I also learned a lot about working on a healthcare team, and about the roles of the different people on the team.  I especially enjoyed a talk from one of the Chaplains about the spiritual teachings on death and dying offered by many of the different religions from around the world.  From intake meetings, to care conferences, I got to see it all!  And everyone was so welcoming and made me feel right at home.

One of my most rewarding moments this week was with a sweet little boy who came in to the hospital on a return visit.  (Our kids in hem/onc are in and out several times for multiple courses of chemo.)  When he came in he was in a great deal of pain.  That combined with his anxiety and shyness made it very hard to connect with him.  We kept checking back with him throughout the week.  Yesterday when we brought bubbles, he actually smiled and made eye contact.  It was pretty exciting to see that rapport beginning to build.

Check back next week to hear more.  I'll try and post reflections each Friday.  Meanwhile, I hope to get some Malcolm pictures up later this weekend.

Internship, Week One Reflections

Hello Family & Friends,

Many of you  have kindly ask how the internship in Child Life is going, so I thought I'd share a few thoughts here.  It's Friday evening, as I write, and I have just finished Week One.  This week was all orientation -- two days of official hospital stuff (policies, infection control, HIPPA training, etc.) and three days of orientation to the Child Life Department, and the internship.  The Child Life days were my favorite, as they including presentations from each department, such as:  Radiology, ICU, Child Advocacy Center, Emergency Dept, etc.  This gave me a look into what Child Life Specialist do in each of these departments.  Throughout the next 14 weeks, I'll have the opportunity to spend a day shadowing a CLS in a different department.  I get 5 or 6 shadowing days, so I'll have a chance to try out several of the ones that intrigued me this week!  Monday will see me start my first 7-week rotation, which will be on the Hematology/Oncology/Bone Marrow Transplant floor.  I am very excited about this placement!

So, beyond the factual report, here are my reflections . . . . Orientation was, undoubtedly, the "info overload" week.  I have so many handouts, articles, and booklets, I think the pile outweighs Malcolm!  It will take me far longer than this weekend to digest it all.  But that is to be expected.  The other intern (there are two of us) came straight to the internship from a college program in Child Life, so this gives her a broad base of reference and experience that I seem to be missing.  Mostly, I've been playing catch-up learning all the terminology and field-specific vocabulary. (And my knowledge of specific child development theories is a little dusty!)  The contrast of seeing the other intern pick right up on the terminology and such, while I'm thinking "Wait, what does that mean?" has left me feeling slightly . . .  I'm not sure.  Not "less confident" . . . maybe a  little "unprepared."  Not really sure.  I think after I've had a week on the floor, I will be completely caught up with this part, so a week from now it probably won't even be an issue.

Overall, I'm wildly excited to be here.  This will be an amazing opportunity, and I'm looking forward to getting everything out of it that I can!