Familiar Face in Surgery : Parents Ease Child’s Operation Concerns

Wearing green scrubs, a hair net and a blue surgical mask, Mary Ann Azzolina carried her 3 1/2-year-old daughter Rachel into the operating room.

Holding tight to her precious green “blankie,” the shy girl with long black lashes was about to have an outpatient hernia repair. But in a break from medical convention, her mother would stay with her in the operating room while anesthesiologist Brian Levine put her in an unconscious state.

Rachel cuddled in her mother’s lap, relaxed but interested, as Levine rubbed a small plastic mask with bubble gum flavored lip balm to hide the musty taste of anesthetic gas. On command, the preschooler began breathing deeply into her “magic mask.”

“Good girl,” Levine and Rachel’s mother coached. In a few minutes, a smile flickered across the girl’s face. Her eyes closed, opened briefly, then closed again as she collapsed in her mother’s arms. When Dr. Levine lifted Rachel to the operating table, Azzolina left the room and her daughter’s 45-minute surgery began.

Parents are barred from most operating rooms in Orange County and nationwide. In some cases, a tearful, even shrieking child is wheeled away by an unfamiliar doctor or nurse while worried parents watch the double doors to the surgery room close behind them.

Levine, following the lead of specialists in Washington, is apparently the first Orange County doctor to challenge this age-old medical tradition. His new method has stirred some controversy, but Levine--board certified in pediatrics and anesthesia--believes that explaining surgery to a child and then allowing a parent in the operating room for anesthesia can relieve a child’s anxiety--and make the experience less traumatic for parents.

Further, Levine says--and some research confirms--the technique can prevent postoperative trauma, such as nightmares or bed-wetting. In any event, the 42-year-old anesthesiologist argues, it creates a gentler and more “humane” surgical experience.

But Levine’s enthusiasm for having parents in the operating room prompts strong dissent.

Some leading county anesthesiologists and pediatricians encourage gently sedating a child before he leaves his parents for surgery. But they say, allowing a parent in the operating room for anesthesia would be unsafe if a child stopped breathing and a panicky parent got in doctors’ way.

But Levine argues that he carefully selects candidates for anesthesia with a parent along, mostly reserving it for children having elective surgery at the Mission Ambulatory Surgicenter or Mission Hospital Regional Medical Center, where he practices.

In the last three years, “we’ve done hundreds of children with parents in the (operating) room” without incident, he said. Even in some emergency cases, Levine believes that parents can help. For instance, in an emergency condition called epiglottitis, in which the throat swells, “if a child is very, very upset, he can cry so hard, he can close an airway,” Levine said, so bringing parents into the operating room, will help keep the child calm.

Although Levine appears to be pioneering this practice in Orange County, he did not invent it. The innovators--and strongest national advocates--are at Children’s National Medical Center at George Washington University in Washington, where parents have been invited to help with anesthesia for the last 10 years.

Said Dr. Raafat Hannallah, children’s professor of anesthesia and pediatrics: “The point for small children, especially preschool kids, is to avoid the trauma of separation from the parents. . . . For (a child), one of the most traumatic aspects of surgery is to be taken away from the parents.”

Another plus: The practice allows doctors to avoid the use of sedating drugs, some of which carry risks like respiratory depression, Hannallah and Levine said.

But at Children’s Hospital of Orange County and elsewhere, officials say having parents in the operating room is a bad idea. Instead, children who have surgery at CHOC are sedated before being wheeled to the operating room. If a toddler or older child seems “at all uneasy, a nurse will snap a Polaroid picture of the child with his parents” that he can take as “a comfort” into the anesthesia process, CHOC spokeswoman Marilyn Fisher said.

Added the CHOC chairman of anesthesia, Dr. Jeffrey Katz: “There’s a great national debate” about allowing parents into the OR for anesthesia, but “I have yet to be convinced” by the medical research.

On rare occasions, Katz says, he has allowed a parent into anesthesia and believes that the child was probably “calmer” because of the parent’s presence. But most of the time he considers it “too risky.” In a serious anatomical procedure or working on a medically fragile child, “the extra tension of an untrained observer who might faint, or might not understand what they’re seeing when a child is rendered unconscious, distracts the (medical) crew from their team effort,” Katz said.

At UCI Medical Center, the chairman of anesthesia, Dr. Stephen J. Barker, also does not want parents in the operating room during anesthesia. “If something goes wrong--at the extreme, a cardiac arrest--you don’t want the parent there,” Barker said. “If I were a parent, I wouldn’t want to be there.”

For all his concern, Barker is impressed with the way Levine, who performed his anesthesia residency at UCI, is allowing parents in the operating room. “Having Mom and Dad in the OR is controversial,” Barker said, “but I think what Brian is doing is great.” Like Levine, Barker advocates making anesthesia as pleasant as possible for children. He wants children and their parents to attend a UCI preoperative clinic about a week before surgery so they know what to expect.

And on the day of surgery at UCI, the parents are often present as the anesthesiologist sits on the child’s bed, displays the plastic mask and, like Levine, asks a child to select a flavored lip balm to hide the smell of the gas, Barker said.

Children are then given preoperative medication to make them drowsy. “By the time we take them away from their parents . . . they’re very groggy and sleepy and quiet. The anesthesiologist usually carries them in his arms,” Barker said.

Barker agrees that “children tend to be more well behaved in the recovery room if they have a good separation (before surgery) from their parents. They’re quieter, not agitated and screaming.”

Certainly, such induction methods for children are a far cry from those used on children a dozen years ago.

Recounts one doctor of those harsher days: “We would put them on a bed and roll them in (to the operating room). They’d have both hands on the rails, and they’d be sitting up in bed with a terrified expression on their face, like ‘What are you going to do to me?’

“And you’d clamp on a mask, fast, to speed induction. Of course, they breathe fast when they’re screaming,” so induction proceeded quickly. Also, the doctor said, “you learn, as an anesthesiologist, how to hold a kid down with a minimum of effort.”

Certainly, Rachel’s surgery did not appear to be a trauma for her or her parents.

At Levine’s “preop clinic,” several days before her operation, Rachel played with her sister, Lauren, 5, while Levine discussed her medical history and briefed her parents on the risks of surgery.

She got more interested when Levine handed her a coloring book showing a girl going into surgery. When Levine showed her a plastic anesthesia mask and then gave it to her to take home, she initially tossed it aside. But at home, in the four days before surgery, Rachel and Lauren played with the plastic mask--trying it on themselves, their dolls, and their toy animals, Mary Ann Azzolina said.

On the morning of surgery, the Azzolinas arrived at the Mission Ambulatory Surgicenter at 8:30 a.m.--Rachel carrying her “blankie” and a toy Dalmatian. She wasn’t nervous, her parents said, just hungry and annoyed that she had not been allowed her morning apple juice.

In the preoperative holding room, Rachel sat on a gurney as her mother and a nurse dressed her in surgical pajamas decorated with Looney Tunes characters. Her surgeon, Dr. Gary Mackie, examined her briefly, noting that Rachel’s heart rate was only 65 beats per minutes. “She shows no signs of fear,” Mackie said. “She knows this is approved. There’s really no separation” from her parents.

By 9:30 a.m., sitting on her mother’s lap in the operating room, Rachel’s heart rate was still 65. When Levine turned on the anesthetic gas, Rachel drifted into unconsciousness, pale but calm.

“You know,” the mother said, a little tearful as she left Rachel in the operating room and the surgery began, “she doesn’t even know I’m not there. She thinks I’m still holding her.”

Ninety minutes later, Rachel went home with her mother to a house full of balloons and a day of rest on the living room couch. In the aftermath of her surgery, the biggest problem would not be anxiety, her father, Philip Azzolina, said, but following doctor’s orders to keep the dressings dry--”No baths for a week. That’s going to be something,” he said.

Philip Azzolina said he appreciated Levine’s preoperative clinic and especially his decision to let a parent join Rachel during anesthesia. “It’s hard enough as an adult to have surgery, but for a child, it’s really hard. And so is waving goodby to your kid.”