The call came early one morning. Rich and Christine werevery upset. Their 6-year-old daughter, Mariella, had seena flashing light in her left eye that would not go away. Atrip to the emergency department revealed a smallretinal tear.
The call came early one morning. Rich and Christine were very upset. Their 6-year-old daughter, Mariella, had seen a flashing light in her left eye that would not go away. A trip to the emergency department revealed a small retinal tear. The ophthalmologist wanted to operate the next day to prevent a major tear and to save Mariella's vision. Rich and Christine wanted me to meet with her before surgery.
I asked myself several important questions: Could one meeting with a young child be helpful? How much should I say to the parents and to the child when time is short? Could I trust that a child as young as Mariella would know how to use the consultation to her best advantage or would it be more effective if I structured the time according to my own notion of what might be useful?
Like mother, like daughter
I first became involved with Mariella's family when Christine had a major retinal tear 4 weeks after giving birth to Mariella, her fourth child and only girl. Christine immediately underwent major eye surgery. For 8 weeks afterward, she had to lie face down and motionless to allow her reattached retina to heal properly; she could not lift anything, including her infant daughter, and she was unable to breast-feed.
I was called in then to help Christine, who was anxious about the outcome of her surgery and about the impact the constraints of her recovery would have on her baby and family. I visited Christine's home twice weekly and offered a combination of interventions. I talked with her about her feelings, treated her anxiety and despair with antidepressant medication, and dispensed parenting advice. Occasionally, I would play with her sons and elicit their ideas and questions about what was going on. My main focus was to help Christine get through her ordeal, which she was experiencing as a trauma.
So, when Rich and Christine called me that morning about Mariella's own unexpected ophthalmological crisis, I agreed to meet with the 3 of them. Rich and Christine were at a loss; the surgery would take place within 24 hours. They had no time to buy doll furniture to create an operating room so that Mariella might play out what was to come, nor did they have time to read her books about children in hospitals.
Mariella and her parents trudged into my office late that evening for the emergency appointment. Christine plunked down in the patient chair while Richard pulled up the rocking chair that I kept in the corner of my office. Mariella slumped her gangly frame against her mother's legs and absently swirled her finger across the carpet.
During our meeting, Mariella sobbed quietly. She had been told that any abrupt motion of her head, including "hard" crying, might make it more difficult for the doctors to fix her eye. As I looked on, Rich and Christine tried to explain the operation to their daughter. Their main concern was to assure Mariella that she would get through the surgery and be all right. They explained to her that the 3 of them would go to the hospital the next morning and that they would stay together until the anesthetic caused Mariella to feel very tired and unaware of what was happening to her. (Friends had told them to distinguish between "going to sleep" and anesthesia.) The doctors would fix her eye and she would not experience any pain. The medicine would make her forget all that would occur in the operating room-including memories that might upset her.
Mariella was not happy with her parents' explanations. "Why are you telling me all this?" she asked. "Stop talking so much."
Meanwhile, Rich and Christine were pressing their daughter to say that the information they were sharing was helping her. "Now do you understand?" Rich asked. They asked her, "Now are you feeling safe?" over and over with rapid and loud speech. Despite their best intentions, this was beginning to look to me like an interrogation.
I gently explained that nothing Christine and Rich could say would help Mariella feel better. She needed to know what was going to happen, but it was not going to calm her fears. Having never had surgery or any serious medical interventions before, it was perfectly natural for Mariella to have dire expectations despite her parents' reassurance. Mariella wanted the next day to be like every other day; she would be with her family, go to school, play with friends, and then come home. She was angry and scared, and those feelings made sense given the circumstances. I told Rich and Christine that they should not expect her to feel better about the surgery until it was over.
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.