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Colin
Colin

1mo

INFJ

Cancer

8
7

The Boy Who Held His Water

As a float nurse in a behavioral health hospital, I never quite know what my day will look like. Sometimes I work with children, coloring superheroes and asking them what their superpower would be and how they’d use it to change the world. Other days I am working in the adult crisis stabilization unit trying to talk to patients who hear voices telling them to kill the other patients. This week, I was in charge of the unit for adolescent boys. In the early morning quiet, while other patients still slept, I met Jamie—a 13-year-old pacing the common room. Jamie was battling not just the internal turmoil of PTSD from a sexual assault, compounded by a diagnosis of autism and ADHD, but also a mysterious affliction that affected his ability to urinate, intertwining his emotional and physical pains in a Gordian knot. Jamie came to be in our care on a wave of crisis precipitated by a sudden pharmaceutical supply chain disruption. The availability of his ADHD medication? None—a situation that escalated his underlying anxieties to a peak that manifested in suicidal ideations. His physical complaints, however, were just as pressing. He described sharp pressure-like pain while clenching at his sides and frustration with his body’s stubborn refusal to release urine—a condition that brought him not only discomfort but a profound sense of helplessness. After my initial assessment, I suspected a urinary tract infection. My suspicion was confirmed by the emergency department we sent him to and where I also work. Jamie returned to us with a diagnosis of UTI. Antibiotics were prescribed, but his grandmother did not consent. She did not believe he had a UTI and did not believe in antibiotics. Yet, the signs and symptoms were there: the dysuria, the hematuria, proteinuria, the suprapubic pain, the elevated white blood cells. Yet again, when reevaluated by our internal medicine team, doubts were cast on this diagnosis. The lab results, they argued, were borderline; not fully convincing of an infection that warranted antibiotics. This left the nursing staff in a diagnostic limbo, with Jamie's pain and frustration growing each day. As I pondered Jamie’s case, I considered not only the physical symptoms but the psychological overlay. Although I could not administer antibiotics to treat his probable UTI, I needed to intervene in some way to help him manage his symptoms. Some people with autism can have magnified sensory responses to sensations like bladder fullness, turning the normally mild discomfort into something unbearable. His PTSD, with its hyperarousal symptoms, could be keeping his sympathetic nervous system in an undue state of alert, causing his body to retain urine as if bracing for a perpetual threat inappropriately. Something potentially exacerbated by the communal restrooms where privacy is limited, the boy who threw a chair through the window, or that he's away from home in a strange place with strange rules. Intent on providing Jamie some relief, I turned to an old technique with new applications—progressive muscle relaxation, focusing particularly on the pelvic floor. Alongside, I offered him a primer on the physiology of the urinary system, tailored to his intellect and curiosity. I explained how muscles and the nervous system control urination. When we engage in slow diaphragmatic breathing, we stimulate the vagus nerve which can inhibit our sympathetic nervous system creating the conditions for easier micturition. These interventions had a remarkable effect. Within a short period, Jamie managed to void 800 ml at once, a victory that brought a rare smile to his face. It was more than enough for us to collect a repeat urinalysis. It was also more than anyone's bladder should have to hold. Adults typically feel the need to pee when their bladders contain around 300 ml of urine. However, our challenges were far from over. While his immediate pain was significantly better, he continued to experience discomfort and needed repeated coaching to help him urinate on schedule. Progressive muscle relaxation is a practice after all. Any celebrations over the repeat urinalysis would need to be delayed as our lab's turnaround time for such a test is 48 hours. The delayed urinalysis results finally confirmed the initial suspicions of a UTI, but by this time, Jamie’s condition had escalated to pyelonephritis, marked by fever and signs of a systemic infection. This necessitated an urgent transfer to a children's hospital better equipped for more intensive care. Reflecting on Jamie’s case, I am profoundly reminded of the nuanced responsibilities we hold as nurses in a psychiatric setting. Each challenge—from ensuring that Jamie’s physical symptoms were not dismissed as merely psychosomatic to navigating the complexities of diagnostic disagreements—teaches a valuable lesson in patient advocacy and interdisciplinary collaboration. Jamie's journey underscores the critical importance of treating each symptom with thorough investigation and respect, regardless of a patient's mental health history. It also highlights the delicate balance required to maintain professional relationships when opinions diverge. Despite the setbacks, our small victories—like his smile after successfully managing to void—reaffirm my commitment to patient-centered care. These moments underscore the importance of empathy, patience, and persistence. They remind me why I chose this path: to make a meaningful difference in the lives of those who are often misunderstood and overlooked. As Jamie moves to a facility that can provide him with the intensive care he now needs, I hold onto the hope that our efforts have set him on a path to recovery that respects both his mental and physical needs. Moreover, Jamie's case is a reminder that advocating for clearer communication and facilitating discussions among the medical team is among the most important jobs any clinician can do and would have been instrumental in transcending the diagnostic limbo that delayed his care. This experience reminds of the importance of holistic approaches to patient care that do not artificially separate the mental from the physical. In striving to provide the best care for Jamie, I am reminded that at the heart of all our efforts lies a profound commitment to seeing beyond the surface, recognizing the human spirit’s resilience, and tirelessly working towards an integrated approach to health and healing. (edited)

The Boy Who Held His Water

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