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Teach Your Children
Pediatric surgery becomes less stressful when patients — and parents — know what to expect
By Fiona Phelan
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Business New Haven
6/20/2000
By: Fiona Phelan
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Parents prepare their children for most of life's events - the first day of kindergarten, a move to a new town, an airplane trip, emergencies at home, vaccinations, visits to the dentist - any number of unfamiliarities that might make a child anxious.
But not enough parents take the time to adequately prepare their children for surgery - an oversight that can make the procedure more stressful for everyone.
Of the 5,000 to 6,000 children who undergo outpatient surgery each year at the Children's Hospital at Yale-New Haven Hospital, only about 60 percent participate in the hospital's pre-admission program. Across town at the Hospital of Saint Raphael, the percentage is closer to 50 percent, according to staff.
Participating in pre-admission programs, say physicians and nurses, can significantly reduce the stress of both child and parent.
“Sometimes the pre-admission tour is more important for the parent than the child,” acknowledges Pat Schiavi, acting patient-care manager for ambulatory care at St. Raphael's. “If the parent's stress is reduced, then the child will feel less anxious.”
St. Raphael's relies on the child's surgeon or physician to inform the family about the hospital's pre-admission tour. During the program, patients and their families meet with an anesthesiologist and a nurse. The medical staff answer questions and discuss how anesthesia will be administered and whether the child would benefit from pre-medication prior to going into the operating room. If an operating room is available, the family is allowed to look around.
In the hopes of increasing participation in the pre-admission program, the hospital recently revamped the brochure it provides physicians to hand out to parents, says Schiavi. Additionally, St. Raphael's has instituted a new practice of registering all pediatric patients through the outpatient ambulatory surgical center - even if they will later be admitted to the hospital for overnight stay.
Also, children and their families are provided a separate waiting area that includes child-size furniture, books, coloring materials and toys to play with until time for surgery. Because children are usually scheduled for early-morning surgery, they will recover from surgery and anesthesia in a room with other children.
“The more prepared the parent, the more comfortable the child will be,” says Schiavi. “I didn't really understand the stress factor until I brought my niece in for surgery. Even though I'm a nurse, it was still stressful.
“Nobody takes care of your child like you,” she notes. “There's a fear that something's going to happen because it's not you taking care of your child and you're not there.”
Yale-New Haven relies on its own staff to supply information about the pre-admission program. A receptionist calls the family about ten days prior to surgery to schedule a tour that can last from 45 minutes to an hour. During the visit, the patient and family will meet with an anesthesiologist who will take the child's medical history and conduct a physical exam; a nurse who will obtain a health history and provide pre-admission restrictions regarding diet limitations the day before; and a child life specialist who will prepare the child for surgery through pictures, medical equipment, play activities and a tour of the surgery center.
Because of dietary restrictions prior to surgery - no food or drink after midnight the day before surgery - pediatric patients are scheduled early in the morning with many arriving at the hospital by 6 a.m. for a 7 a.m. procedure.
As one parent discovered, the anesthetists are quite strict about ensuring patients adhere to the restrictions. A six-year-old boy was sent home on his scheduled day of surgery because he had nibbled at a pretzel en route to the hospital. The risk of vomiting while under anesthesia and the possibility of food going into the lungs warranted re-scheduling the child's surgery.
Watching carefully to insure that the child doesn't eat anything; getting up early enough to get to the hospital on time; taking time off of work; arranging care for siblings; worrying about a child's reaction to anesthesia; and providing constant attention upon discharge - are all contributing factors to a parent's stress about surgery.
But the biggest fear, says YNHH's Lisa Caramico, M.D., is anesthesia - an artificially induced insensitivity to pain achieved by the administration of gases or injection of drugs.
“It scares parents, I think, because the parents have no control over what's going on once they pass their child over to the anesthesiologist,” says Caramico, an anesthesiologist at Yale for seven years.
“People don't have a good understanding about anesthesia,” she continues. “Most people don't realize that we're most often medical doctors, although there are nurse anesthesiologists working under the supervision of a medical doctor.” At YNHH's Children's Hospital, all pediatric patients are given anesthesia by doctors of anesthesia who work solely with children, she adds.
“Families that go through the pre-admission program come in on the day of surgery knowing what to expect,” says Caramico. “Some parents don't prepare their children at all and that makes our jobs more difficult. Most children do better when they know what to expect.”
Yale's Medical Director of Pediatric Surgery Center and Chief of Pediatric Anesthesiology, Zeev Kain, M.D., has been studying parental and patient anxiety for the past eight years. One of the studies conducted at the hospital questioned whether the child's anxiety would decrease if parents were allowed in the operating room during the procedure. That did not prove to be the case, says Kain.
“Bringing parents into the operating room does not make a difference,” says Kain. “Some parents freak out and become more anxious, and that makes the patient more anxious.”
As an added tool to help parents prepare for surgery, Yale-New Haven is in the process of creating a videotape to show what goes on in the operating room, says Kain.
“We are trying to using a variety of intervention modules - the videotape, the pre-admission tour, pre-medication and music - to make surgery as non-threatening as possible,” he says.
But such programs aside, parents are still stressed. “I was a wreck,” says Cindy Christo, mother of three-year-old Tyler, who had ear-tube surgery at 18-months, and six-year-old Alyssa, who had her tonsils removed.
“My daughter was fine, she didn't seem scared at all. I think because we talked about what was going to happen, she wasn't afraid.” Christo did not participate in the pre-admission program offered by the Bridgeport Surgical Center.
Similarly, Sue Cornell has not participated in a pre-admission tour for any of her son's four visits to Yale. “It was certainly offered to us, but I didn't think it was appropriate for his age at the time.” In fact, on their most recent visit to the hospital, the Cornells did not tell their son about his impending surgery until waking him up early the morning of appointment. “I think that worked fine for him,” she says.
However, Kain says programs like Yale's can make a difference. “At a time when many hospitals are curtailing or downsizing their pre-admission program, Yale's program is more extensive than ever before,” he says. “Our program is still underutilized, but we see it as a mission to offer this to parents.
“When parents bring their children to the program, we can really individualize how they are going to be treated on the day of surgery,” Kain says. “We will have a better understanding of everyone's concerns and determine what will be the easiest way to get the child to the operating room.”
Some children, he says, are content to travel in one of the hospital's ride-on toys to reach the operating room. Other patients - and parents - respond better with a pre-surgery sedative that makes the child sleepy and relaxed after about 15 to 20 minutes.
“We have a variety of weapons in our arsenal,” says Kain. “What works for one child will not always work for another. We don't like to give medications unless it's indicated.”
Since 80 percent of the children undergoing outpatient pediatric surgery at Yale are between one and four years old, about one-third are given pre-medication prior to surgery, says Kain. This is an age, he adds, at which separation can be a problem. If the patient is calm before leaving the parent, the procedure becomes much less stressful for everyone.
In addition to toys, games and pre-medication, YNHH has also introduced music into the operating room. Noting that dentists very often use music for their patients, Kain conducted a study to determine whether music would be beneficial in the operating room as well.
“We turned down the lights in the OR, we reduced the talking amongst the nurses and staff and played music as the children entered,” explains Kain.
“Modern technology moves at such a frantic pace that sometimes we need to invest more in human technology, “says Kain. “We'll try anything that makes the experience easier for patient and family.”
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