When we take on the responsibility for solving another person’s problems, we essentially steal their opportunity to grow, build resilience, and gain mastery over their own lives.
"It is the ultimate misuse of our power to take responsibility for solving problems that belong to others. Our role as witness is to create a safe space for them to sort through the issues of the day, offering understanding & interpretation along the way,"
-- Kelly Koerner, 2011.
Captain Scab set down her boot at the ragged edge of Healing Hollow, where a brave little explorer—named Wound—had just arrived after a sudden fall. The land smelled of iron and dust. "We must map this place," whispered Scout Platelet, a tiny scout in a bright coat, who hurried to the wreck to call the first responders.
First Responders: The Platelet Patrol
Scout Platelet blew a tiny horn and more Platelet Patrols swarmed in, plugging gaps and tying flags across the torn path. They formed a sticky bridge to stop the river of red from flowing. "This will buy us time," Platelet said, pressing down a soft tarp to keep the landscape steady.
Setting Up Camp: Inflammation Station
Soon the town bell rang and Inflammation Station opened. Red-Shirted Macrophage and Neutro the Messenger arrived, clearing debris and sending signals to neighboring valleys. They lit bonfires to chase away invaders—tiny bacteria who sometimes try to claim new land. The fires cause heat and swelling, but they are careful: the smoke is part of the clean-up, not the end of the town.
Building the Scaffold: The Granulation Guild
After the cleanup, the Granulation Guild arrived—a bustling crew of fibroblasts and new blood vessels. Fibro the Weaver spun collagen threads, weaving a pink carpet of strong fibers over the gap. Tiny builders called angioblasts tunneled new streams (capillaries) to bring fresh supplies. The ground grew bumpy and rosy as the guild worked: this was new tissue growing up from the base.
Paving the Path: Re-epithelialization Road
Explorer Epithelium led a parade of skin cells marching from the edges inward. They spread flat flags and smoothed the new carpet until the surface looked whole again. Their march is careful and steady; they patch the surface so the town can once more keep out invaders.
Remodeling: The Restoration Council
Weeks later, the Restoration Council met. Collagen threads were rearranged and tightened; the town remodeled its streets for strength rather than quickness. Scarstone replaced the bumpy new build with a tidy seam—stronger but a bit different in color and texture than the old landscape. Over time, the seam faded, becoming a quiet line that told the tale of the explorer's journey.
A Note from the Mapmaker
Not every expedition goes the same way—some lands need more help if invaders are many, if supplies are scarce, or if the explorers are old and tired. But in most voyages, the Platelet Patrol, Inflammation Station, Granulation Guild, Re-epithelialization Road, and Restoration Council work together so the land of the cut becomes whole again.
For this patient visit, I shared participation 50/50 with my preceptor. A 7-year-old female patient was accompanied by mother and brother for annual well-child exam. Patient scored a 28 on the Pediatric Symptom Checklist for Child 6-16, which is a positive score (greater than 27). The True-tone Hearing screening test was performed and passed. The vision wall chart was attempted, and patient is currently established with an eye doctor and has an appointment scheduled in one week.
She has a past medical history of autism spectrum disorder (diagnosed 3.5 years ago), specific developmental disorder of motor function, mixed receptive-expressive language disorder, and today was diagnosed with hypertrophy of tonsils with hypertrophy of adenoids. Mom reported some muffled voice concerns, loud breathing when sleeping, discipline issues at home, and concerns that child struggles with anger/emotional regulation with siblings. The exam findings revealed normal vital signs, 2+ tonsils without erythema or exudate and no other significant findings. There is a family history of tonsillar enlargement.
A release of information was signed by parent, in order to obtain diagnostic records for autism disorder for the clinic records, as school is wanting the diagnosis records to formulate the IEP or interventional education plan. I also requested in-house behavioral health counselor to visit with parent regarding emotional regulation concerns. A referral was made to the local otolaryngologist for possible tonsillectomy and adenoidectomy procedures, because of the adenotonsillar hypertrophy, muffled voice, and obstructive concerns. These issues are causing problems for sleep, which may in turn be increasing behavioral problems. According to Nationwide Children’s (n.d.), “School-aged children who do not get enough sleep are more likely to have behavior problems” (para. 4).
Upon review of her immunization record, it is notable that she is behind on all vaccinations, so the following were recommended to begin the catch-up schedule: Tdap, Hep A, Hep B, MMR, varicella, and inactive poliovirus (Advisory Committee on Immunization Practices [ACIP], n.d.). The immunizations were not carried out during this visit because of caregiver refusal, as the parent does not consent to immunizations at this time. I discussed the importance of immunization per ACIP schedule, as well as recommendations through Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatricians (AAP). Discussed concerns with risk of delaying immunization, including risk for child death due to vaccine preventable disease. Parental vaccine refusal form completed.
A reason for refusal is not needed for the medical record, unless there is a medical indication for not receiving the vaccinations. Why? Because regardless of the non-medical reason, the child is missing out on multiple opportunities to be protected from serious illnesses that could result in permanent disability or death. It does not matter why, because the result does not change. Public school is typically the system that requires a reason, and acceptable exemptions vary by state.
In Kansas, there is a form for medical exemption only. If parent/guardian is refusing vaccinations based on the child being “...an adherent of a religious denomination whose religious teachings are opposed to such tests or inoculations...” then they must provide a statement written and signed by one parent or guardian (Kansas Department of Health and Environment [KDHE], 2019, p. 1). I do not know of denominations that have such oppositions, honestly. I am still searching though!
Side note: Despite APRN now having authority to practice independently in Kansas, the medical exemption form (and several other state forms) still requires a physician’s signature, and specifically indicates MD or DO under the signature line!
The visit note in the medical record for this patient reflected the following results:
Hep B ped/adol (Not administered - Refused: Parental decision).
Again, the reason for refusal is not appropriate for the medical record unless it is a medical reason, which is uncommon. Some instances of medical exemption may include an allergy to some immunization components, having an immune deficiency, or having an illness such as cancer.
In Missouri, they do not mince words when describing the unexpected consequences that may befall the unvaccinated child and family.
“To protect those who cannot be vaccinated and the entire community, unimmunized children could be excluded from school and child care during disease outbreaks. Exclusion from care can cause a hardship for the child and parent, however no exceptions are made, regardless of the circumstances” (Missouri Department of Health and Senior Services [MDHSS], 2022, para. 3).
Thoughts and Feelings
This is a tough one for me. I spent four months as a contractor with the CDC (through Maximus) developing scripted responses and training materials with an aim to resolve vaccination hesitancy. I thoroughly enjoyed the experience and gained great insight into those reluctant to trust governmental agencies with their health. Primarily these were folks that fall into the minority classification, and possibly with a lower health literacy level, yet with valid reasons for mistrust and even resistance. Just do an internet search on the Tuskegee study, the forced hysterectomies/mass sterilization of Native American women, and the use of Henrietta Lacks "immortal cells," just to name a few... among many other examples of abuse and deceit, which both vindicates and explains their level of mistrust.
Anyway, those are hesitancy or refusal issues I can understand – sort of – but I am having a very difficult time maintaining rational discernment and unbiased perception when it comes to the recent years’ exemptions in the name of religion.
It’s not that I am unable to get on board in support of those religious freedoms and choices, but more so that I question the robust increase in religious exemptions over the past several years.
I question whether or not they are truly grounded in religious doctrine or if they are simply politically driven.
I am forever bothered after learning that “...religious objection is often used by parents as an excuse to avoid the vaccination of their children...” rather than it being a real exception for vaccination (Pelcic, et al., 2016, para. 4).
Evaluation of Strengths and Challenges
The challenge for me is of course not opening my mouth to challenge the parent/guardian belief system or decision. The challenge is to not create a new brain injury category called shaken adult syndrome. The challenge is to educate and not persuade, to inform and not antagonize, to support and enlighten rather than judge and disparage. The challenge is to not go home at the end of the day, defeated, because every well child checkup resulted in a parent’s refusal to vaccinate.
The strengths are that I succeed in most of the above-listed dichotomies. At least for now, I keep my mouth shut, I don’t murder-shake the adults. I educate, inform, and enlighten. I don’t support the decision or choice, but I do support the fact that they get to make a decision or that they get to choose. Unfortunately, on more than one occasion I did go home at the end of the day fully defeated, because every well child checkup resulted in the parent’s refusal to vaccinate. But my strength is wearing thin, and I feel myself slipping. I feel myself slipping into judgment and irritability because my expectations are apparently too high to be met. But why should I lower my standards?
Analysis and Self Reflection
Well in true analytical fashion, I recognize that I am powerless over another’s choice, and that it is unethical for me to attempt to persuade a patient or their guardian/parent into a choice they don't want. Although my wily guiles are capable of persuasion in the most challenging circumstances, I recognize that as the medical provider I must remain unbiased (as much as possible) and objective. It is so hard to sit back and watch what is happening, inevitably, to our herd immunity status.
I think the scariest, most upsetting part for me, is that I catch myself being inched closer and closer to secretly make an “instawish” that the kid catches some preventable disease and suffers - just to “teach the parent a lesson.” THIS IS NOT WHO I AM OR WHO I WANT TO BE.
As if it is my job to "scold" and mother the patient or family. When I think about being turned into that person, I feel sick to my stomach, and am thankfully reminded that I will do whatever I can to never become that person.
I actually don’t even like movies where we are rooting for a protagonist that started off the movie by breaking the law or something, because the movie implicates excuses and triggers understanding as to reasons behind their unlawful or unethical behavior. I get caught up in it and then realize I have been rooting for a bad guy the whole time - and the movie tricked us all.
Take away:
My hope is that you take the following terms with you as you leave this page: shaken adult syndrome and murder-shake. Those were a 3am contribution to the post and I woke up the next day not remembering and also choosing not to remove them because they just add "flare" hahah
So when we use a screening tool for ACEs, we can use a procedure code to capture it. That code is:
96160 Administration of patient-focused health risk assessment instrument (e.g., health hazard appraisal) with scoring and documentation, per standardized instrument
If you are interested in the ICD 10 coding options that may be used for ACEs in adults (and sometimes children), I did a little research and found some - there are probably more but here are a few according to ICD10Data.com (n.d.-a):
Z00 - Z99Factors influencing health status and contact with health services
Z62Problems related to upbringing
Z62.81Personal history of abuse in childhood
Z62. 812 Personal history of neglect in childhood
Z62.898Other specified problems related to upbringing
Z62.9 Negative life events in childhood
Z91.49 Other personal history of psychological trauma, not elsewhere classified
Z87.828 Personal history of other (healed) physical injury and trauma
Z91 Personal risk factors, not elsewhere classified
And theZ59 Child Codes section has individual diagnoses codes for SDOH! From Codify (n.d.) here they are:
Z59 Problems related to housing and economic circumstances
Z59.0 Homelessness
Z59.1 Inadequate housing
Z59.2 Discord with neighbors, lodgers and landlord
Z59.3 Problems related to living in residential institution
Z59.4 Lack of adequate food
Z59.5 Extreme poverty
Z59.6 Low income
Z59.7 Insufficient social insurance and welfare support
Z59.8 Other problems related to housing and economic circumstances
Z59.9 Problem related to housing and economic circumstances, unspecified
Terrific, right??
So, we can use the Z59 codes to capture issues related to pediatrics, and the codes in the previous section are probably better used for adults, if I am understanding it correctly. Finally, here are a few more interesting codes:
R68.13 Apparent life threatening event in infant (ALTE)
R68.19 Other nonspecific symptoms peculiar to infancy
Z62. 21 Child in welfare custody
The Diagnosis Related Groups (DRG) dataset 951 is for "Other factors influencing health status" (ICD10Data.com, n.d.-b, title). "DRGs are used for determining reimbursement and as an indicator for other types of reporting such as budgeting, physician profiling, clinical outcomes, case mix calculation and clinical research" (The University of Texas Medical Branch at Galveston, n.d., para. 13).
Additional note to remember:
Z codes in general are used as secondary codes, unless it is for an encounter (Z00.00, Z00.121, Z00.129, etc).
And here is a linked resource that is terrific: Tips for ACEs Related Coding It summarizes coding practices, like I attempted to above. It was put together by the New Jersey Chapter of the American Academy of Pediatrics (NJAAP) (2019).
The University of Texas Medical Branch at Galveston. (n.d.). Description of coding and DRG assignment. Revenue Cycle Operations. https://www.utmb.edu/rco/Employees/DCDA
I was assigned some courses on ACEs and there was a great TED talk on the subject. Here are links to what I was to use in preparation for answering the questions below. I highly recommend the training, it was great!
The questions were simple, and were meant to be a basic reflection of learning posted in a group discussion.
Discuss your thoughts about what you have learned about ACE's. Did you know anything about them before this week's assignments?
I did know about ACEs before completing this week's assignment(s), and I have always felt very fortunate to have had a childhood that resulted in the score I have for ACEs. I first learned about ACEs in 2016 when my sister in law was completing her third master's degree - yep third. She is a Vice Principal now, but was initially a special education teacher, then a grade school principal in a school district filled with kids from socioeconomically challenged homes. The average ACE scores for the kids in her elementary school was seven. Seven!!
She was discussing it with me in 2016, and I had not heard of ACEs before, that I recall. What she shared with me, and learning about ACEs, inspired me to learn as much as I could about SDOH. I eventually went on to write my master's thesis with a focus on teaching nursing students about SDOH, and for my capstone I developed a curriculum for nursing students to learn about SDOH and I addressed ACEs and the correlation between SDOH and ACE scores throughout the curriculum.
If so, did you learn anything new?
I actually did learn something new this go-around. I did not realize that the ACEs are strongly considered preventable - I mean - I guess maybe cynically speaking, I did not feel empowered to succeed in preventing most ACEs. According to Centers for Disease Control and Prevention [CDC] (2023), "...we must understand and address the factors that put people at risk for or protect them from violence. Creating and sustaining safe, stable, nurturing relationships and environments for all children and families can prevent ACEs and help all children reach their full potential" (para. 13).
Who knew? "...can prevent ACEs..." I certainly didn't know.
How will what you learned affect how yourprovide care for your pediatric patients?
I suppose this new awareness entreats me to gather as much information as I can about school, community, government, and private resources that I can share with pediatric patients and their parents/caregivers, when I recognize signs of ACEs in my patients.
According to the Cleveland Clinic (2023), signs of an adverse childhood event can include:
Fear of other people
Difficulty sleepingor frequent nightmares
Bedwetting
Changes to their mood
Difficulty showing affection towards friends or family
Avoiding situations or events that relate to a traumatic experience
Difficulty learning in school
But what are the warning signs before an ACE occurs?
There aren't really warning signs, as much as there are common risk factors. The Cleveland Clinic (2023, para. 9) indicates the common risk factors for ACEs include:
childrenassigned female at birth
minority racial or ethnic groups
children with socioeconomic challenges
children of caregivers who experience stress
children who have family members/friends with substance use disorder or other mental health condition
And although "ACEs are common across all populations," (CDC, 2021, para. 13), I will be more likely to help prevent ACEs for my patients if I:
maintain awareness of the most common risk factors
identify the risk factors during my assessment of the patient
intervene to extirpate the risks I can identify
What I learned from this assignment, will strongly impact my practice moving forward, and ultimately benefit the patients that are in my care.
For this patient visit, I shared participation 50/50 with my preceptor. The 5-year-old female patient was accompanied by her current guardian, presenting for annual well child exam. Change in guardian care since 06/2023 with siblings (2 brothers). Current foster parent reports that patient and siblings have moved foster homes 6 times in the past 18 months. Pt has been having allergy symptoms of sneezing and runny nose for about one month. Patient tends to have dry skin despite moisturizer use. She will sometimes have itching/scratching to genital area.
Her past medical history includes lactose intolerance, specific developmental disorder of motor function, mixed receptive-expressive language disorder, adjustment disorder, allergic rhinitis, xerosis cutis, and congenital preauricular pit with history of infection. She was evaluated with ENT for possible excision vs tertiary referral. She has had a cyst in right ear that comes and goes.
On exam vital signs were within normal range, and there was a noted right preauricular pit, with no pre or postauricular swelling or discharge seen. She did not pass her Pure-tone audiometry hearing screen (MedlinePlus, n.d.), but this may be related to her age and ability to interpret instructions for screening process, more than her ability to hear. Nonpruritic skin with mild xerosis to extremities.
Her ASQ-3 developmental screen demonstrated developmental concerns for fine motor skills, which will need monitoring. Learning activities were discussed with the foster parent/guardian, and AAP Bright Futures parenting guide was provided and discussed. A TAP-TAM book "Bears on Chairs" given.
Note: TAP-TAM is the early literacy program in Kansas, and stands for, “Turn a page, touch a mind” (Kansas Chapter American Academy of Pediatrics, 2017). It is an amazing program, held in high esteem along with programs like Dolly Parton's Imagination Library (The Dollywood Foundation, n.d.).
The plan consisted of a referral made to Audiologist as follows: 5-year-old female with failed hearing screening 7/19/23, history preauricular sinus/cyst formation with abscess management by ENT in 2021. No current infectious concerns. Referral with audiology through ENT requested.
Additionally, patient was to start a daily antihistamine as instructed. She could also use saline spray in nose a few times a day to flush out allergens. Also discussed allergen reduction strategies, avoidance of strong-smelling soaps and detergents, as well as avoidance of bubble baths. Patient was to also avoid prolonged sitting in a wet swimsuit with outdoor activity. Samples of CeraVe were given for home use for routine care. Her follow up was planned for one year, for next well child exam.
Thoughts and Feelings
The nature of the exam, findings, referral, and plan - was not the lesson for me in this situation.This was a shy, submissive child that sat powerless on the exam table. She intermittently made eye contact but did not hold it for more than a second or two, before looking away or down at her feet. This child had been passed around to six different foster homes in 18 months. There was so much about this patient and her circumstances that exposed the broken systems in our country.
I thought pediatrics would be difficult, and that this rotation would be challenging for me on many levels, but I did not expect the emotions I have felt in caring for this population. My clinical rotation is at a Federally Qualified Health Center (FQHC). FQHC are usually located in rural or underserved communities and provide care and services for those most impacted by SDOH - social determinants of health (HealthCare.gov, n.d.).
Evaluation of Strengths and Challenges
This visit was not about the medicine for me. This visit triggered compassion that overwhelmed me, and sorrow that burdened me. Despite being considered the richest and most advantaged country in the world, the United States have not done enough to care for our children. We have hungry, sick, impoverished children, yet we are living in a nation of abundance. We promote birth and yet we fail to preserve the well being of those born.Jacobson (2022) has gathered many statistics that provide further insight on just how well we are caring for the children in some areas of the country...and just how well we aren't.
We have children that have been removed from their homes or removed from their parents for various reasons. And then there are the children that were cast aside by their own parents, seemingly discarded. It was not just this patient either - it seemed like this patient was the tipping point for me. I remember driving home from clinic that day and just feeling discouraged...and crying for all of the kids in "the system" who get shipped around from home to home. Actually crying... like call-your-mom-crying and overcome with emotion. Crying not because this was a new revelation, but it was conspicuous and routine in this setting.
Developing my skills to align more with practicing medicine has been very difficult. I don't have a clear boundary established where I give myself permission to treat the patient and not take on their problems as my own.
Analysis and Self Reflection
I asked my preceptor how he is able to separate his feelings, how he is able to do this - in this population - day in and day out. He said that there is no other way to do what we do everyday, but to establish and maintain boundaries in our profession. He said that we have to approach the care with compassion, but from a bird's eye view.
I appreciate that he doesn't take on the burdens of our patients. It made me think of a quote from a book I had for my BSN, by Koerner (2011), "It is the ultimate misuse of our power to take responsibility for solving problems that belong to others. Our role as witness is to create a safe space for them to sort through the issues of the day, offering understanding & interpretation along the way" (p. 138).
Action Plan
Jones (2019) said it best in her online article, "...setting boundaries doesn’t signal you don’t care or that you are selfish...Boundaries show you value a relationship enough to be thoughtful about making sure it thrives" (para. 5). My plan is to develop and maintain trusting relationships with patients, and boundaries are a great foundation for building those relationships.
I cannot risk caregiver or provider burnout, by taking on the hardships of patients and thinking it is up to me to solve their problems for them. I will not allow myself to own the issues of the patients in my care. I can only provide supportive counseling, reassurance, guidance, and empathetic listening, along with feedback and encouragement regarding solution focused changes.
Koerner, J., & Bender, S. (2011). Chapter 5: Quantum Healing the Power of Integration. In Healing presence: The essence of nursing (2nd ed., p. 138). essay, Springer Pub. Co.
