Mariella nodded solemnly, acknowledging my comments. She then looked up and glanced around the room. "Can we stop talking now? Can I do something with Dr Helper?" Her parents gladly turned her over to me. Mariella perked up immediately, bypassing me for the toy collection against the far wall. She moved quickly, as if eager to flee her parents' sorrow and bad news. Then, one after another, came the demands, none of which seemed to have anything to do with the upcoming surgery or her eye condition. "Do you have a doll house? Where are your dolls? Do you have some action figures? I want some puppets, monster puppets. Do you have some soldiers?"
Fortunately, my playroom is well stocked and I could point her toward whatever she wanted. Mariella calmly created a doll family of a girl, a mother, and a father. She placed them in the house on a bed and said firmly, "Time for sleep. Tonight you all sleep together."
I started to ask her about this arrangement but she cut me off. "Quiet, they're trying to sleep." Suddenly, she screamed, "They're coming!" Mariella put the soldiers in a tank and threw them at the family, scattering mother, father, and child. Then she grabbed a shark puppet and stuffed the doll family into its mouth. Next, she picked up Batman and pretended to fly him like an airplane. Mariella's parents and I watched in silence as Batman swooped down, grabbed the shark, shook the family from the shark's mouth, and dropped them back into their house. "They are safe now," Mariella pronounced. "The shark is gone."
Before I could form the words to describe the dramatic scene I had just witnessed, Mariella looked over to her mother. She pushed the glasses that she wore for nearsightedness and that had continually slipped down her nose during her play firmly back to their proper place. "I'm tired," she yawned. "I want to go home now. I'm really hungry. Can I have a snack before bed?" Her parents and I realized that she had, through undirected play, worked out something about her scary eye problem and was ready to face the night and the surgery the next day. I told Mariella that I would call tomorrow so that she could tell me all about her time in the hospital.
Surgery and postsurgery
Mariella had a hard time in the preoperative room; unfortunately, her parents' attempt to distinguish anesthesia from sleep backfired. "Come on, sweetie," the preoperative nurse said, "you've got to take your sleep medicine so the doctor can fix your eye." After Mariella was rolled into the operating room, the anesthesiologist also referred to the anesthetic as sleep medicine. This confused and frightened Mariella, who had to be forced to comply.
In retrospect, had we better prepared Mariella for the use of the word "sleep" attached to the medicine and surgery, she might have accepted the medicine without a struggle. At least the language that her trusted parents had used would have meshed with the language of these strangers wearing surgical masks. But could using the term "sleep" in association with surgery and medical procedures lead to sleep difficulties at home?
Christine called to let me know that Mariella's procedure had gone well. Because of the location of the retinal tear, she did not have to spend recovery time with her head immobilized and was not confined to bed. The surgeon was confident that he had saved Mariella's eyesight.
Mariella's most pressing concern postoperatively was her fear of going to sleep. In addition, she was worried about what had happened to her while she was asleep during surgery. Initially, Mariella did not like the idea that she would be unable to recall things that had been done to her. "What did they do to me?" she repeatedly asked her parents. "What if they didn't do what they said they would do?" This gave way to a fear that she would remember the pain associated with having an operation. She wanted to know if "sleep wears off," referring to the anesthesia. "Will I ever remember everything that happened?" Her parents' reassurance helped Mariella with her fears, and she felt comforted by their explanations.
Mariella still has a long way to go in processing her experience. She feels panicked every time she sees anything unusual in her fields of vision. Sometimes she thinks that she is seeing ominous flashes, only to find out from her doctor and parents that they are fleeting and therefore nothing to worry about. She has developed somatic complaints, including headaches and stomachaches. She is fearful that her body is not a strong one. But for the most part, Mariella has recovered. She is back in school, having friends over, and playing and fighting with her brothers the way she did before the surgery.
Christine is having more difficulty. She feels that it is her fault that Mariella has eye troubles. She has nightmares about her own eye surgery. We all agreed that I would resume work with Christine and that Mariella would see a colleague for play therapy to work on her concerns.
The value of one-time consultations
So what happened during that preoperative consultation? I think that it was a relief for Mariella to know that her parents were seeking advice and that she did not have to comfort them. I believe that it was useful for the parents to know that they were helping Mariella, even if their words did not make her feel happy or comfortable. Mariella had a chance to play out her ideas over what was about to take place to save her eye: aggression with biting sharks, renegade soldiers who disrupt families, the hope for rescue by a superhero, fear of separation, and finally, relaxation within the safety of the reunited family. Story line and feelings were expressed with great benefit to Mariella.
Finally I, who am by nature and style rather chatty with my patients, learned that sometimes you barely have to say a word.