Considering the circumstances, Josefina Banuelos looks calm.
In half an hour, her 8-year-old daughter, Beatriz, will have her tonsils removed. And this morning's trip to the surgery center has not been smooth. Just as they left home, Josefina grabbed a glass of water from Beatriz, who had forgotten her doctor's orders not to eat or drink after midnight. Then on the way to the hospital, they had a car accident. "I'm relieved there was no damage," sighs Josefina.
Now, Josefina sits at her daughter's bedside, half-heartedly accepting a challenge to arm-wrestle. As Beatriz is wheeled away to the operating room, Josefina kisses her goodby and then retreats to a waiting room, settling in a straight-back chair and sipping coffee. Surgery will take an hour. At least. "I'm a little nervous," she admits.
Legions of parents understand Banuelos' vigil--and her jitters. More than 1.8 million children under age 15 undergo inpatient surgery every year, according to the National Center for Health Statistics, and countless others have outpatient surgery for "routine" procedures like tonsil removal.
Emotionally, surgery can be just as rough on parents as on young patients. "A lot of parents have even more trouble than the child facing surgery," says Dr. William Hall, chairman of the ear-nose-throat department at Cigna Healthplans, where Beatriz underwent surgery. Regardless of how positive a parent's frame of mind, presurgery anxiety is the rule. "And it doesn't seem to matter how minor the surgery is," adds Susan Perry, a child development specialist at Memorial Miller Children's Hospital, Long Beach.
The worst time for parents is waiting the eternity that even the briefest surgery seems to take. Drinking coffee. Reading but not comprehending magazines. Trying not to focus on the 101 potential disasters that might happen. And debating the question that can't be answered immediately: Did you explain it all well enough so your kid's not scared silly? For kids, the ride to the operating room can be just as long. "Kids often imagine things will be worse than they really are," says Vera Terrell, a developmental therapist at St. Vincent Medical Center. "They worry, for instance, about riding in a wheelchair down to the lab for tests, just because they have never done it before." And the aftermath of surgery can be even worse than the anticipation. Says Beatriz: "The worst part was waking up after the surgery. My throat was sore, and I couldn't talk very well."
"Nothing will take away all the anxiety," says Dr. Barbara Ferguson, a child psychiatrist at St. John's Hospital and Health Center, Santa Monica. But it need not be paralyzing. Parents can do much to reduce anxiety, for themselves and their children, even if the surgery is emergency. Enlightened hospital personnel can help with advice and formal programs. And future technological advances--such as skin patch delivery of presurgery medicine--promise to reduce the psychological trauma even more.
While there's no pat formula for reducing anxiety before childhood surgery, experts say pre-admission tours help introduce children to a hospital environment. These half-hour tours are becoming more common and more sophisticated, covering such nuts-and-bolts issues as how to operate the call buttons and hands-on demonstrations of an anesthesia mask. (If not, experts suggest scheduling a visit with the anesthesiologist, since the mask frightens most children.) Some hospitals give children disposable anesthesia masks so they can practice with them at home. Other hospitals send children home with coloring books, complete with pictures of hospital equipment and staff.
Role playing is part of some advanced tours. "For elementary schoolchildren and some preschoolers, we use dolls and surgical equipment to tell a story about what will occur, from presurgical medical tests to after surgery," says Terrell of St. Vincent Medical Center. Terrell's doll family--dressed as mom, dad, child, doctor and nurse--"helps eliminate fear of the unknown."
Parents can continue the role playing at home, using the kids' own dolls or even stuffed animals. "But don't give them too much information," Perry warns. Suppose the child will undergo a myringotomy, a procedure in which an incision is made in the eardrum to insert a ventilating tube. "Tell the child where the tube will be inserted and what it will do," Perry suggests. "And stress the positive results of the surgery. For instance, parents should say: 'You won't have earaches. You will hear better.' " Banuelos took just such a practical approach in explaining the tonsillectomy to her daughter. "I told her: 'The doctor will take something from your throat that makes you snore at night.' "
There are library books about childhood surgery, such as "Curious George Goes to the Hospital." Besides letting kids know peers have been in the same boat, it reduces fear of the unknown. "Reading about it beforehand is a tremendous help," believes Dr. Elmer Crehan, a pediatrician at the Hospital of the Good Samaritan. "Then kids know what to expect."
Role playing and reading can help parents uncover their child's misconceptions. Even procedures that seem ordinary to adults may frighten children. Blood tests are a good example, says Perry who advises telling the child exactly how much blood will be taken. Otherwise, fantasy reigns. "Little kids in particular worry all their blood will be taken," says Perry.
In explaining possibly scary medical tests and procedures, the right choice of words is crucial. "Substitute injection for shot ," Perry suggests. "It's a longer but softer word." If a test involves the use of contrast material, don't say dye, a word often interpreted by children as die. "Call it coloring instead," Perry suggests.
When talking about general anesthesia, most doctors tell parents to avoid the phrase knocked out. But they don't agree on the best alternative. Suggests Dr. Henry Green, an anesthesiologist at Childrens Hospital of Los Angeles who rubs flavored lip balm on the top of the anesthesia mask so patients smell strawberry, not anesthesia: "You will fall asleep and in a little while you will wake up." Another expert tells parents to avoid the word sleep. "When pets get old, they get put to sleep," reasons Dr. James Diaz, an associate professor of anesthesiology at Tulane Medical School, New Orleans. Instead, he tells parents to refer to the anesthetized period as a nap. "And emphasize waking up at the end of it."
Regardless of the preparation, expect school-age children to adapt better than younger children. "School-age children are used to being confined," Perry explains. "And they're more verbal in expressing fears and asking questions. Toddlers, from 18 months to 3 years, have a more difficult time. They're just beginning to break away from parents and then someone imposes restrictions. Often they can't verbalize their frustrations, so they become even more frustrated."
Frustration isn't the only rampant presurgery emotion. Many children feel out of control, and understandably so. Parents can give them back some control, experts say, in a number of easy ways. Let them pack their own suitcase, or, if they're too young, let them help pack. Taking along a teddy bear, a favorite blanket or toy is a good idea, even if a child seems too old for such transitional objects. One preteen veteran of several surgeries relies on his stuffed bear to do more than cuddle, he hints: "Surgery is scary. You never know when the doctors will mess up. Usually they don't. But it helps if you take along a teddy bear. He's always awake."
Preparing a child for emergency surgery, of course, is more difficult. "Focus on comforting the child," Hall says. "Sympathize with the child's pain and reassure him he will be fine after surgery. Stress the result."
Whether surgery is emergency or not, children often show behavioral regression afterward. It's nothing to worry about, says Ferguson, if it's temporary and not extreme. "An older child doesn't need to be treated like a baby, but he does need an empathic stance," Ferguson says. Where to draw the line? Somewhere between empathy and endless ice cream, she suggests.
After surviving surgery, some children may even brag about their hospital success stories. It's also common to save some hospital souvenir--even disposable bedpans--to prove their bravery to friends. When she comes home from the hospital, Beatriz says she'll keep her ID band in a drawer at home.
CHILDHOOD SURGERY: How Parents Can Help Kids Get Through It
If the surgery is non-emergency:
* Check out library books that describe the hospital experience. ("Curious George Goes to the Hospital" by Margret and Hans Rey, and "A Hospital Story" by Sara Bonnett Stein.) * Book a pre-admission tour. * Role-play the surgery at home with dolls or stuffed animals. * Let your child pack his own suitcase or help pack. * Take along a familiar object such as a teddy bear or blanket. If the surgery is emergency:
* If possible, grab a favorite toy, book or blanket. * Offer emotional support and stay with the child en route to the hospital. * Tell your child as much as you know about what's going to happen. Enlist the help of hospital staff once you arrive. Source: Susan Perry, director of Child Life Department, Memorial Miller Children's Hospital, Long Beach.