by Tilda Shalof
In and out of consciousness.
Kitch saw each child who visited the Medical Centre, even the ones with splinters and mosquito bites that I could treat myself. At first, I assumed it was his thoroughness, or to catch something I may have missed, but Wendy explained the real reason.
“Our parents feel better knowing that a doctor has seen their child. It’s what they expect. Besides, the doctor can bill for his services. He doesn’t get paid if the nurse treats the child.” Wendy went on to explain another situation where health care and commerce converged. “As for the American campers, it’s problematic since he can’t bill for his services but is still exposed legally. He takes care of them out of the goodness of his heart.”
It was a pleasure working with Kitch and I had a lot to learn from him. Also, it was a relief to have him be the “enforcer.” When a twelve-year-old boy needed stitches for a cut on his head, Kitch forbade him to swim until they were removed. The boy sulked, argued, and went swimming anyway. When the cut got mildly infected, Kitch stepped up to be the bad guy who scolded him. But Kitch also had the advantage of knowing the kids better than I did from having been at the camp for so many years. He could see through fabricated excuses to get out of going on a tough canoe trip. He uncovered a case of self-sabotage, when a child damaged his own braces to nab a few days home to visit the orthodontist! He was exceptionally good at identifying faked (whether consciously or not) ailments. One morning, a group of girls, all from the same cabin, showed up together with identical headaches and stomach aches. He checked their schedule and discovered they were supposed to be doing the climbing wall. He knew they didn’t like that activity so he prescribed pottery class for them instead. When the dance or drama instructors came in with various injuries or muscle strains – or simply a case of rattled nerves – they often requested painkillers or something to help them relax. Kitch managed to calm them down just by sitting with them and giving them attention. He spent a lot of time talking and, perhaps more importantly, listening, to them. One day he went out to the crowded waiting room and brought in one little girl right away. “This is an mid,” he told me. “A muffin in distress. All she needs is a hug.”
I envied his mastery of the art and the craft – not just the science – of healing children. “So much of what I do is explaining, reassuring, and consoling,” he said with a shrug, as if it were nothing.
These skills were a big part of my nursing practice, too. In the hospital I always made note of when I offered my patient “comfort measures.” At camp, I recorded my intervention as “tlc.” How well I’ve learned that Tender Loving Care can be just as effective as a medication.
I learned a lot about sore throats from Kitch after we started to see a run on them for a few days. “More than ninety percent of sore throats are viral and therefore do not require an antibiotic. It’s unlikely to be strep throat if the patient has a runny nose, stuffy ears, cough, but you can’t rule it out altogether. Strep throat is worrisome because of dire complications that can develop if left untreated, such as throat abscesses, kidney inflammation, or the main one, rheumatic fever. Prudent medicine would dictate that a swab be sent for each and every sore throat, but it’s not always feasible to do so.” He then told me about one summer when a mysterious sore throat went around camp. The mystery was that out of one hundred and seventy-five swabs that were sent to the lab, only one came back positive and that child wasn’t even symptomatic. He then had to start an antibiotic on a child who felt perfectly well.
“The question to always ask is: Is it viral, bacterial, or allergic? The answer will guide your approach,” he said.
As for earaches, they always need to be examined, he explained, but few patients needed antibiotics, only painkillers to ease the discomfort, then follow-up. Most resolve by themselves. Under Kitch’s tutelage, I improved my examination of the tympanic membrane inside the ear canal. We examined each child and compared notes.
“Hey, you get to see a part of me that I’ll never see,” one kid said, as I peered into his ear. “My eyes, too. I’ll never see my own eyes, except in a mirror.”
“You’re right,” I said. “I hadn’t thought of it that way before.”
There were lots of skin ailments I’d never encountered. Kitch taught me how to diagnose eczema, athlete’s foot (an infection not always found on the foot), heat rash, and others, such as ringworm (which is not a worm, but a fungus). And I no longer worried that every red and swollen mosquito bite would turn into infective cellulitis or the dastardly flesh-eating disease. Nonetheless, I did a careful examination, demarcated the reddened area with a marker so I could track its progress, took baseline vital signs, gave an antihistamine, and followed up the next day.
One time I discovered a galloping skin infection by accident. I happened to bend down to pick up a dropped pill (within the allowable five seconds, of course!) and noticed a big, red, wet sore on the back of the leg of a boy named Wesley.
“Oh, that,” he said. “It’s nothing.”
But on closer inspection, I found another sore, and then, further up his leg, a few more. His other leg was also covered in these sores.
“They’re mosquito bites,” he said. “They don’t bother me.”
“They bother me!” I started him on antibiotic ointment, but even so, they quickly spread onto his arms and chest. Within a few days, an entire cabin of eleven-year-old boys all had unsightly, open sores all over their bodies. Kitch took a quick glance at one of them, scanned the others, said one word – impetigo – and started them all on a ten-day course of antibiotics. “Skin infections like these are unavoidable in close quarters. We have to eradicate it – preferably before Visitor’s Day,” he said with a wink.
Kitch taught me a lot of practical skills. One evening after dinner, a bench fell on a young camper’s foot. Ouch! It was bleeding under the nail and swelling up fast. “It’s a subungual hematoma,” Kitch said. I prepared a sterile field and assisted Kitch to perform an incision in the nail to release the blood under the nail. I didn’t dare tell him about the makeshift procedure I had performed at Camp Na-Gee-La using a needle heated up by a cigarette lighter, with a first-aid book at my side.
Another skill I learned from Kitch was removing ticks. These pesky little insects got entrenched on the skin and held on fast. Together we removed a bunch of them from a young boy’s legs. “You want to make the tick squirm but not squeeze it, ’cause you’ll leave the pincers embedded in the skin. Gently coax the tick to let go.” He explained the importance of getting it in its entirety so as to avoid the patient contracting Lyme disease or Rocky Mountain Spotted Fever, rare infections, to be sure, but possibilities all the same.
Splinters had to be extricated with even more delicacy. A Ph.D. thesis could be written on the topic of splinter extraction! What a world of difference there was in each child’s reaction to those irritating, teeny tiny logs of wood embedded in their tender skin. Some kids ignored them while others picked at them quite savagely. Another group of kids, admittedly a splinter group, cried so much and became hysterical at even the prospect of removing them that Kitch would apply a topical anaesthetic cream, scrub in, and perform mini-surgery while I comforted the sobbing children. Personally, I found removing splinters a very satisfying experience. I was deft with the needle and I loved seeing the pride children felt after overcoming their fear. When a child asked, “Will it hurt?” I told the truth: “Yes, it will, but I know you can handle the pain,” or “Yes, but I’ll help you get through it.”
Headaches were very common. Kitch believed they were often stress-related and usually ran in the family. “You do a little digging and it turns out the parents have headaches too and everyone in the family is stressed out. They’ve all been to specialists and have had specialized scans and tests, but there are no findings. The parents are disappointed in the lack of diagnosis, but not every feeling of being unwell can be diagnosed, especially in children,” he said. “Sometimes children experience a collection of vague
, transient symptoms for which no particular illness can be identified. Often, they resolve with time, through no intervention whatsoever.”
Stomach aches were another common problem. Often it was the same child, over and over again, complaining of them. “Most stomach aches turn out to be nothing,” Kitch said, “but you always have to be vigilant for the signs of something serious like appendicitis. Ask the kid to jump. If the kid can’t jump, you know for sure the pain is severe. Another thing to remember is that the farther the pain from the belly button, the more likely it’s something serious like a bowel obstruction. Always keep in mind that pain that wakes a kid up during the night almost always has a cause.”
He summed it all up with an insight that captured so much about medicine and nursing, too: “You have to know what you are looking for. You only see what you know to look for.” That struck me as true about many things in life.
One day, Kitch called me out on my cover-up job. He noticed that I often waved off kids who stopped by for Band-Aids for minor scrapes or cuts. I usually sent them packing without their trophy.
“Studies have come out recently proving that covering a wound helps promote healing and prevents scarring,” he said.
Oh, well, evidence-based practice must prevail! I had a new respect for Band-Aids after that.
Kitch also cited scientific evidence that helped me understand another medical issue I’d been wondering about. I had asked him about the excessive number of EpiPens that had accompanied so many children to camp. “There has been an alarming increase in peanut allergies among North American children over the past few years, but I agree with you that there’s probably a percentage of EpiPens that are sent purely out of parental anxiety and doctors’ fear of liability. Normally, it wouldn’t be a problem, but overreaction is causing a lot of anxiety in children who worry unnecessarily about dying from anaphylactic shock. Problem is, if the parents don’t know for sure, they err on the side of caution and send up the drug.” He shrugged his shoulders. “Who can blame them?”
Kitch was always ready to share with me his vast knowledge and grasp of the most up-to-date scientific findings, tempered by his years of hands-on, real-life work with children. He was particularly skilled when it came to treating their bones, limbs, and joints.
“I’m quite certain the locals aren’t running off for x-rays as frequently as our city kids,” Kitch said with a chuckle. “Our kids simply aren’t used to walking outdoors. They walk in shopping malls and on paved sidewalks. They’re not nimble-footed around rocks and their eyes aren’t attuned to twigs or roots sticking up out of the ground.”
Again, it’s about seeing what you know, I thought.
“Either they don’t have as many injuries as we do, or they do but suck it up and allow nature, rest, and time to heal their injuries, as they usually do, anyway. Personally, I prefer to avoid unnecessary x-rays; I’d rather take a ‘wait and see’ approach. But at this camp, I’ll send a stubbed toe for an x-ray, otherwise parents have been known to come up here and take the kid to the hospital themselves. At times, I practise defensive medicine. I may order things that aren’t necessary because I know the parents will demand it.”
I wondered what the local hospital staff thought about our sending campers for x-rays for every fall, twist, or turn of a joint or limb. I found out later when I’d gone to that small (only thirty beds) but busy hospital and heard one of the nurses grumbling. “You’re giving us lots of work,” she said, and muttered under her breath, “Bunch of clumsy oafs and hypochondriacs at that fancy camp.”
Limb injuries could be complicated. Kitch brought me in on interesting cases.
“Watch this,” he said when a boy came in after an injury on the soccer field. His arm hung at his side at an odd angle. Before the child even knew what was happening, Kitch deftly popped the dislocated shoulder back into place. The boy looked shocked, then pleased to have his arm back where it belonged.
“Show us your wrist,” he told a ten-year-old boy who was brought in after an accident on the baseball field.
The child winced as he placed his right hand on the table. I examined his hand gently but thoroughly, poking and prodding it and putting it through its complete range of motions. The boy held himself rigidly, his face twisted in pain. I looked carefully at his hand and arm, palpated them all over, but could find nothing abnormal.
Kitch whispered a clue. “Always examine both sides.”
The boy had kept his left wrist on his lap, hidden under the table. When I took it out to examine it, he yelped in pain. He had been too scared to show me the arm that was causing him pain. However, with one look anyone could see it was fractured. It was folded back on itself with the bone poking up through the skin.
Kitch asked the boy to tell us exactly what happened. He had told me how important it was to always get a detailed account of the “mechanism of injury” – meaning, what happened. That account would always provide clues to the diagnosis. The boy said he’d landed on the palm of his hand when he fell, running for a catch in the outfield.
“Just as I thought,” said Kitch. “It’s a FOOSH – a Fall On Out-Stretched Hand.” He pointed out the bend in the wrist. “That’s a ‘silver fork deformity.’” He reminded me to check the radial pulse and showed me how to make a splint that effectively immobilized the limb, snug enough to provide support, but with enough give to allow the inevitable inflammation that would soon follow and not to restrict circulation. Together we tied a sling that would comfortably bear the weight of his arm.
“But did you make the catch?” Kitch asked the boy.
“Yup,” he said proudly.
“Way to go,” Kitch said and high-fived him on his uninjured hand.
What a wake-up call for me! I’m quite sure I would have eventually discovered the obvious problem, but the incident showed me how easily one’s thinking can be restricted to what the patient chooses to present. It was a reminder to stay open-minded, not limit my thinking, and be a detective, especially when examining children.
Kitch taught me how to “buddy-tape” sprained fingers together, how to make finger splints out of tongue depressors, and the differences between a sprain, a partially torn ligament, from a strain, which was a stretched ligament. “In both cases, it’s the same treatment: rice – Rest, Ice, Compression, and Elevation. After that, let pain be your guide. Pain will tell you what the child can and cannot do. The only thing is, at camp, it may be difficult to distinguish between pain and homesickness. Sometimes homesickness expresses itself as pain. We’ve seen them limp, moan, and groan their way in here, and after a little attention, they hop, skip, and jump out of here. For homesickness, the best thing is to keep them busy. Run them ragged all day so that they’ll fall right to sleep at night.”
Unfortunately, that plan wasn’t working for Alexa Rose, who was busy and happy by day and homesick and unhappy by night. I was beginning to think that homesickness was a catchall term for the process of learning to comfort oneself. At camp, far from home and parents, kids are challenged to soothe themselves. So many kids seem to have little ability to withstand discomfort, to push through the pain, or to be encouraged by the old, but oh-so-wise truism This, too shall pass. They thought there was a pill for everything, even transient sadness or temporary dis appointment. And it would be easy to believe that was true, what with the availability of so many over-the-counter products. I was amazed how easily so many children could describe their symptoms and request specific products. They were fluent in the language of analgesics, antihistamines, decongestants, and anti-inflammatories. They scrutinized product labels and conversed knowledgeably about ingredients. Many knew the name of the drug they wanted, requested the tablet, capsule, or syrup formulation, and could even state the dosage they took. They expected a remedy that offered quick relief. And they didn’t want the pain merely blunted or diminished; they wanted it gone. Nothing less would do. They looked at me reproachfully when I couldn’t make their problem go away.
&nb
sp; “I know,” Kitch said with a sigh, agreeing with me. “My patients are always disappointed if they leave my office without a prescription.”
I told him about a day in town when I’d dropped by the drugstore to pick up an order Wendy had put through. The pharmacist handed me a bag of antibiotics and painkillers. “There must be some gravely ill children at your camp,” he had said.
“Actually, they’re pretty healthy,” I said. “They just don’t realize it.”
I kept my eye on Wayne, the reluctant swimmer who always kept his red bracelet prominently displayed. Often he sat on the dock, watching the others swim or paddle canoes or kayaks. I never once saw him get wet. The swim staff eventually gave up and ignored him. In addition to a fear of swimming, Wayne worried about germs and infection from toilet seats. He liked to use the bathroom in the mc, but only after wiping it down first. Kitch called him an FLK – a funny-looking kid – but I knew Kitch well enough by then to know he meant it as a term of endearment.
Wayne showed up one day looking worried. “I think I have beaver fever.”
I tried to keep a straight face. “Lie down, young man, and I’ll examine you.”
“It’s an infection from beaver pee in the lake.” He felt his forehead. “I may die.”
“Is it by any chance swimming period?” I asked, noticing his counsellor at the door, Wayne’s swim trunks, goggles, and towel in hand.
“How did you know?”
On another occasion, Wayne took me aside to tell me he was itchy.
“Where?” I asked quietly.
“Back there. You know, in the anal area.” He squirmed around as he spoke.
I nodded and asked him a few more questions, but he refused to be examined, so Kitch had to make a guess. “We could give him Vermox in case he has pinworms. It’s harmless,” Kitch reasoned.
This was another drug I was unfamiliar with. “Does it have any side effects?”
“Only one,” he said, his eyes twinkling. “It may cause camp-wide hysteria.”
