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Preparation of the Child for Surgery: Responsibility of the Referring Physician
PREPARATION OF THE '::UILD FOR SURGERY
Responsibility of the Referring Physician COLIN C. FERGUSON, M.D.
The successful outcome of an operation performed on a child depends not only upon the skill of the surgeon, but also upon the work of a team of individuals concerned with the total care of the child. Included in this team are the referring physician, admitting clerks, internes and residents, nurses, ward aides, "toy ladies," anaesthetists, the surgeon, and the parents of the child. An important member of this team is the referring physician, because, of all the members, he alone knows the child, the parents and the family situation, and from previous experience he is likely to know how the parents will behave under stress. Because the child and the parents know and trust their doctor, they are more likely to reveal their worries and fears to him than to strangers. Both from a physical point of view and from an emotional standpoint, the referring doctor is in a better position to help prepare the child and the parents for surgery than are any of the others who will be concerned with the care of the child once he is in hospital. Depending upon the age of the child, and upon whether the operation to be performed is elective or emergency, the role of the referring physician in the pre-operative preparation of the patient will vary to a great degree. URGENT SURGERY IN THE NEWBORN
When a baby is born with a serious abnormality requiring urgent surgical treatment, the young parents are usually completely overcome by the tragedy that has fallen their way. They will be absolutely incapable of making any rational decisions about the care of their child, and all 979
980
PREPARATION OF THE CHILD FOR SURGERY
Fig. 13. Incubator* used for transporting infants at the Winnipeg Children's Hospital. The heating unit can be plugged into the cigarette lighter socket of an automobile. Oxygen (if indicated) is supplied by a portable tank.
decisions and arrangements must be made by the referring physician. Having contacted the surgeon and informed him of the baby's condition, the referring physician must then make arrangements to transfer the infant from the newborn nursery to a surgical centre equipped to handle major surgery in this age group. If the maternity hospital and the surgical centre are close by, transfer can usually be made easily in a warm car, the blanket-wrapped baby being carried by a nurse. If, as often happens, the infant has to be transported some distance, then, as Bishopl has described, more satisfactory arrangements must be made. Many hospitals have portable incubators which can be warmed as required, and these are ideal (Fig. 13). Every effort should be made to maintain the small infant's body temperature at a normal or slightly sub-normal level. Even under the most severe climatic conditions the tendency is to overwarm the child and to produce an elevation in body temperature which, by increasing the metabolic demands, may be detrimental to the seriously ill infant. During transportation, oxygen should be available for use if indicated, but it should not be routinely used. If the abnormality involves the gastro-intestinal tract, so that vomiting, with danger of aspiration, or so that increasing abdominal distension may be a serious complication, then an indwelling nasal catheter * The Accli-Bator Portable Incubator, Model 510, manufactured by the Accli-Bator Company, 830 North La Brea Ave., Los Angeles 38, Calif.
COLIN C. FERGUSON
981
should be inserted, and oesophageal or gastric contents aspirated. During transportation the nurse to accompany the infant should be instructed to aspirate the catheter intermittently, using a syringe. To guard against complicating infection, particularly pulmonary infection, an antibiotic should be administered to the child before transfer. Because transient hypo-prothrombinaemia of the newborn may complicate the operation, it is wise for the referring physician to administer to the baby a small dose of vitamin K (not exceeding 2.5 mg.). A competent nurse should accompany the child, and, if possible, the father should go too, so that he can fill out the necessary admission forms and sign the operative permission. If the father cannot accompany the baby, then it is essential that the referring doctor send this necessary information and an operative permission form, signed by either the mother or the father. Any roentgenograms taken on the infant should be sent to the paediatric surgical centre, since time-consuming repetition of these diagnostiC] studies may be avoided. In all instances the referring doctor must send along a brief history containing essential information about the family history of other congenital abnormalities, the pregnancy of the mother, the delivery of the child, the post-natal course with particular reference to episodes of respiratory distress, the amount and frequency of vomiting, the type of vomitus, the number of voidings, and the number and type of meconium stools. Any laboratory data must be accurately recorded, and, again, the supplying of this information may save valuable time once the baby arrives at the surgical centre. An account of treatment, intravenous fluids, drugs, and so on, should also be included, since further care of the child may be greatly influenced by this information. Finally, in the note to the surgeon, the referring physician should suggest the best arrangement by which the surgeon can inform the physician and the parents of the outcome of the operation and the progress of the child. The referring physician must make every effort to bolster the morale of the mother, so that she may make a prompt recovery, and be able to care for her baby when he is subsequently discharged from the paediatric centre. ELECTIVE SURGERY IN INFANTS AND SMALL CHILDREN
When an infant or a small child under the age of four requires an elective surgical procedure, little or nothing can be done to prepare the child for hospitalization and surgery, from an emotional aspect. The small child cannot understand, but the child over two years of age should be informed that he must stay in hospital. He should be told
982
PREPARATION OF THE CHILD FOR SURGERY
that the doctors and all the people in the hospital will make him well again as quickly as they can, and that he will then go home. The referring physician should explain the situation to the parents, reassure them as to the qualifications of the surgeon, and attempt to resolve their fears and doubts so that these will not be communicated to the poorly understanding child. From a physical aspect, however, the referring physician has a definite responsibility. A thorough physical examination should be performed, so that any intercurrent infection or previously undiscovered abnormality may be detected. Before operation is performed, any infection should be treated and cured. A diaper rash should be cleared up, and any anaemia corrected. Pre-existing dietary insufficiency, if' present, should be determined and, if possible, relieved before the time of elective surgery. The immunization of the child should be reviewed and, if necessary, be brought up to date well ahead of the time of hospitalization. Information about drug sensitivity or food allergy and any familial disease should be communicated to the surgeon, so as to avoid complications during hospitalisation. Because of the ever-present danger of cross-infection in the hospital, every effort should be made to make the period of hospitalisation as short as possible. If the infant is being breast-fed, the referring physician, in consultation with the surgeon, should make arrangements for the mother to continue breast-feeding the child while in hospital, or, if this is impossible, for her to pump her breasts at home and have the milk brought to the hospital each day. It is also the responsibility of the referring physician to check on the health of other members of the family, and to treat any infection with which the patient may come in contact. EMERGENCY SURGERY IN OLDER CHILDREN
Obviously, in an emergency situation, there is little or no time for other than the essential preparation of the ill child for the operation. Most of this will be the responsibility of the surgeon himself. The referring physician, however, should introduce the surgeon to the child and to the parents. The child should be told that he is going to have an operation, and that the surgeon will fix the pain or trouble and will make him well again. To the parents, anxious and sometimes almost terrified, the referring physician should briefly outline the situation, and reassure them that the surgeon has handled this sort of illness many times before, and can be relied upon to treat the child to the best of his ability. The referring physician should tell the surgeon essential information about the family, their conduct under previous stress, their worries and
COLIN C. FERGUSON
983
fears, so that when the surgeon talks to the parents, he may have this background of knowledge in reassuring them about the operation to be performed on their child. Their financial situation should be briefly outlined to the surgeon. Many parents in an emergency situation request private accommodation and special duty nurses, and state that expense is of no consideration. The referring physician, knowing the family's financial situation, can see to it that good care is provided, but not unnecessary care which will indebt the family far beyond their financial resources. Any allergies or sensitivities of the child should be noted on the chart. The immunisation to date may be of importance and should be carefully recorded. History of exposure to contagious disease should be determined, and, if the child has been exposed, arrangements should be made for him to be treated in isolation. When the child has been taken to the operating room, the parents should be told where they are to wait and how they will be informed about the operation and the post-operative progress of their child. If the hospital has a post-operative recovery room, the parents should be told in advance that their child will not immediately return to his bed. If the family circumstances do not permit the parents to wait during the operation, the referring physician and surgeon should arrange how the parents will be informed of the results of the operation, and who will do it. Acute laryngo-tracheo-bronchitis constitutes a possible surgical emergency deserving special consideration. This disease occurs most frequently in the winter months, and the respiratory difficulty often becomes greatest in the small hours of the night. If the physician, at the child's house, suspects that the child may require a tracheotomy, he should immediately notify the hospital to have all emergency equipment in readiness. He also should arrange for the surgeon to be at the hospital to meet the child on arrival. The readying of the child for the trip, and the drive through the cold night air, frequently aggravate the respiratory obstruction, so that a child, previously only moderately distressed, may arrive at the hospital cyanosed and desperately in need of tracheotomy. With the operating team in readiness, and the surgeon prepared, this lifesaving procedure can be immediately performed. ELECTIVE SURGERY IN OLDER CHILDREN
Children over four years of age who must have elective surgery can be helped both from a physical and particularly from an emotional or psychic aspect by careful pre-operative preparation. As mentioned before, with young children, the physical condition of the older child should be carefully evaluated and any deficiencies corrected before operation.
984
PREPARATION OF THE CHILD FOR SURGERY
Prugh 2 • 3 has reported that over one-third of children studied, showed some reaction to hospitalisation for either surgical or medical illness, and this reaction persisted for at least three months after discharge from hospital. In actual fact, the proportion of children showing psychic disturbance as a result of hospitalisation or surgery is likely higher than this figure, but minor post-operative behaviour problems may not be mentioned by the parents to their doctor. Much can be done to prevent these emotional problems by pre-operative preparation, and much of this is the responsibility of the referring physician or paediatrician. The child, after having been examined, and the need for elective surgery determined, should be removed from the doctor's office to be entertained by the nurse. The situation should then be clearly and concisely explained to the parents. This explanation must not be too detailed, since details will confuse or alarm the parents, but it should be sufficiently clear so that they can fully understand the need for surgery, and what is to be done. Doubtful, anxious and worried parents will communicate their fears to the child, and every effort must be taken to reassure the parents. The referring physician should instruct the parents in the psychological preparation of their child for hospitalisation. Most children's hospitals have booklets for parents, giving them advice on this, and it is the responsibility of the referring doctor to see that the parents receive this information. If the hospital does not have a booklet of this type, it is the responsibility of the physician to explain to the parents the hospital's admitting routine, the time for admission, the type of accommodation available, the articles of clothing to be taken to the hospital, the visiting hours, and so forth, and he should invite the parents to ask him any questions they might have. If the operation is to be performed within a few days of the office visit, the older child can be told by the doctor that the operation is to be performed. If it is to be delayed for several weeks, the child should not be told of the proposed operation until a few days in advance of hospitalisation. This should be done by the parents. Under no circumstances should the child not be told that he is going to the hospital. Certainly he should not be lied to and told that he is going to a circus or for some other special treat. Fear of the unknown is prominent in anyone, and children are no exception. Usually a careful, calm explanation by the parents or the doctor of the necessity for hospitalisation and what it involves will benefit the child more than any amount of bribery or cajolery. At the Children's Hospital in Winnipeg, every Saturday morning, a motion picture film is shown. * The parents and their child (over four
* L. E. Hackworth: A True Story about Hospitals. Children's Hospital, Los Angeles. Calif.
COLIN C. FERGUSON
985
years of age) are invited to the hospital on the Saturday of the week before the scheduled operation. They are taken on a brief tour of the hospital, including the admitting office and the wards, and are shown the playrooms, the waiting rooms and the cafeteria. Any questions they have about the admitting routine, visiting hours, and so on, are answered by the staff nurse in charge of the tour. They are then shown the motion picture film, which clearly outlines what will be done for the child after his arrival at the hospital. Any further questions are answered, the parents are served coffee, and the children are given a dish of ice-cream. Although not all parents take the opportunity of seeing this film, it is our definite impression that those families who do, benefit greatly. Their child frequently arrives at the hospital for admission almost in anticipation of the experience, rather than worried and fearful of having to face the unknown. Colouring books or comics which describe the hospital and its routines are useful, but care must be taken that these outline the methods used in the hospital to which the child is to be admitted, because serious discrepancies between those described in the books and those of the hospital may confuse, rather than reassure, the child. Playing games of nurse or doctor at home before hospitalisation may also help in the pre-operative preparation of the child, but the success of these games depends almost entirely on the time available to the parents and their intelligence in making the games worth while. A neighbour child, allowed to participate in the game, telling stories of needles, enemas and other unpleasant procedures, will in a few minutes undo any good that the games might otherwise have accomplished. Under no circumstances should the referring doctor misinform the parents or the child with the hope of thus reassuring them. To mislead them that the child will not receive any needles, will not have any discomfort, that the mother can stay all night with her child, and that the anaesthetic will be given in the child's own room, when the hospital has not the facilities to carry out these promises, will lead to distrust and increased anxiety, rather than to reassurance. Above all else, a kindly manner, a common-sense truthful approach, and a clear and unhurried explanation of the need for surgery will be of great benefit to the child and to the parents in avoiding post-operative emotional upsets. DISCUSSION
Most of the foregoing has been written with the assumption that the child will be admitted either to a children's hospital or to a general hospital with a large paediatric service, and that the surgeon concerned will be at least familiar with, if not an expert in, the care of infants and children. If, however, these ideal circumstances are not available,
986
PREPARATION OF THE CHILD FOR SURGERY
then the referring physician or paediatrician must assume a far greater responsibili ty. Not only must he do what has already been outlined, but, in addition, he must assume the full pre-operative care of the infant or child. He must leave all the orders for medication, and may be required personally to manage the pre-operative fluid therapy if dehydration or electrolyte imbalance is present. Only after the child has been improved as much as is possible should the operation be performed. When the surgeon has had little or no experience in the care of diminutive patients, it is well for the referring paediatrician and the surgeon to decide, in advance of the operation, the exact responsibilities each will assume in the care of the baby. By this previously arranged division of responsibility, conflicting orders written by each doctor, and the resulting confusion to which this can lead, may thus be avoided. SUMMARY
The responsibility of the referring physician or paediatrician in the preparation of the infant or child for hospital has been reviewed. Since this varies greatly, depending upon the age of the child and upon whether the operation is urgent or elective, the subject matter has been considered under four headings: urgent surgery in the newborn; elective surgery in infants and small children; emergency surgery in older children; and elective surgery in older children. An attempt has been made to describe the preparation of the child (and of his parents) for surgery, both from the physical and emotional aspects. REFERENCES 1. Bishop, H. C.: Safe Transportation of Newborn Infants for Emergency Surgery. l.A.M.A., 165:1230, 1957. 2. Prugh, D. C.: Emotional Reactions to Surgery. The Non-operative Aspects of Pediatric Surgery. Report of the Twenty-seventh Ross Pediatric Research Conference. Columbus, Ohio, Ross Laboratories, 1958, p. 19. 3. Prugh, D. C., Staub, E. M., Sands, H. H., Kirschbaum, R. M., and Lenihan, E. A.' Study of the Emotional Reactions of Children and Families to Hospitalization and Illness. Am. J. Orthopsychiat., 23:70,1953. Children's Hospital Winnipeg, Manitoba Canada
Responsibility of the Referring Physician COLIN C. FERGUSON, M.D.
The successful outcome of an operation performed on a child depends not only upon the skill of the surgeon, but also upon the work of a team of individuals concerned with the total care of the child. Included in this team are the referring physician, admitting clerks, internes and residents, nurses, ward aides, "toy ladies," anaesthetists, the surgeon, and the parents of the child. An important member of this team is the referring physician, because, of all the members, he alone knows the child, the parents and the family situation, and from previous experience he is likely to know how the parents will behave under stress. Because the child and the parents know and trust their doctor, they are more likely to reveal their worries and fears to him than to strangers. Both from a physical point of view and from an emotional standpoint, the referring doctor is in a better position to help prepare the child and the parents for surgery than are any of the others who will be concerned with the care of the child once he is in hospital. Depending upon the age of the child, and upon whether the operation to be performed is elective or emergency, the role of the referring physician in the pre-operative preparation of the patient will vary to a great degree. URGENT SURGERY IN THE NEWBORN
When a baby is born with a serious abnormality requiring urgent surgical treatment, the young parents are usually completely overcome by the tragedy that has fallen their way. They will be absolutely incapable of making any rational decisions about the care of their child, and all 979
980
PREPARATION OF THE CHILD FOR SURGERY
Fig. 13. Incubator* used for transporting infants at the Winnipeg Children's Hospital. The heating unit can be plugged into the cigarette lighter socket of an automobile. Oxygen (if indicated) is supplied by a portable tank.
decisions and arrangements must be made by the referring physician. Having contacted the surgeon and informed him of the baby's condition, the referring physician must then make arrangements to transfer the infant from the newborn nursery to a surgical centre equipped to handle major surgery in this age group. If the maternity hospital and the surgical centre are close by, transfer can usually be made easily in a warm car, the blanket-wrapped baby being carried by a nurse. If, as often happens, the infant has to be transported some distance, then, as Bishopl has described, more satisfactory arrangements must be made. Many hospitals have portable incubators which can be warmed as required, and these are ideal (Fig. 13). Every effort should be made to maintain the small infant's body temperature at a normal or slightly sub-normal level. Even under the most severe climatic conditions the tendency is to overwarm the child and to produce an elevation in body temperature which, by increasing the metabolic demands, may be detrimental to the seriously ill infant. During transportation, oxygen should be available for use if indicated, but it should not be routinely used. If the abnormality involves the gastro-intestinal tract, so that vomiting, with danger of aspiration, or so that increasing abdominal distension may be a serious complication, then an indwelling nasal catheter * The Accli-Bator Portable Incubator, Model 510, manufactured by the Accli-Bator Company, 830 North La Brea Ave., Los Angeles 38, Calif.
COLIN C. FERGUSON
981
should be inserted, and oesophageal or gastric contents aspirated. During transportation the nurse to accompany the infant should be instructed to aspirate the catheter intermittently, using a syringe. To guard against complicating infection, particularly pulmonary infection, an antibiotic should be administered to the child before transfer. Because transient hypo-prothrombinaemia of the newborn may complicate the operation, it is wise for the referring physician to administer to the baby a small dose of vitamin K (not exceeding 2.5 mg.). A competent nurse should accompany the child, and, if possible, the father should go too, so that he can fill out the necessary admission forms and sign the operative permission. If the father cannot accompany the baby, then it is essential that the referring doctor send this necessary information and an operative permission form, signed by either the mother or the father. Any roentgenograms taken on the infant should be sent to the paediatric surgical centre, since time-consuming repetition of these diagnostiC] studies may be avoided. In all instances the referring doctor must send along a brief history containing essential information about the family history of other congenital abnormalities, the pregnancy of the mother, the delivery of the child, the post-natal course with particular reference to episodes of respiratory distress, the amount and frequency of vomiting, the type of vomitus, the number of voidings, and the number and type of meconium stools. Any laboratory data must be accurately recorded, and, again, the supplying of this information may save valuable time once the baby arrives at the surgical centre. An account of treatment, intravenous fluids, drugs, and so on, should also be included, since further care of the child may be greatly influenced by this information. Finally, in the note to the surgeon, the referring physician should suggest the best arrangement by which the surgeon can inform the physician and the parents of the outcome of the operation and the progress of the child. The referring physician must make every effort to bolster the morale of the mother, so that she may make a prompt recovery, and be able to care for her baby when he is subsequently discharged from the paediatric centre. ELECTIVE SURGERY IN INFANTS AND SMALL CHILDREN
When an infant or a small child under the age of four requires an elective surgical procedure, little or nothing can be done to prepare the child for hospitalization and surgery, from an emotional aspect. The small child cannot understand, but the child over two years of age should be informed that he must stay in hospital. He should be told
982
PREPARATION OF THE CHILD FOR SURGERY
that the doctors and all the people in the hospital will make him well again as quickly as they can, and that he will then go home. The referring physician should explain the situation to the parents, reassure them as to the qualifications of the surgeon, and attempt to resolve their fears and doubts so that these will not be communicated to the poorly understanding child. From a physical aspect, however, the referring physician has a definite responsibility. A thorough physical examination should be performed, so that any intercurrent infection or previously undiscovered abnormality may be detected. Before operation is performed, any infection should be treated and cured. A diaper rash should be cleared up, and any anaemia corrected. Pre-existing dietary insufficiency, if' present, should be determined and, if possible, relieved before the time of elective surgery. The immunization of the child should be reviewed and, if necessary, be brought up to date well ahead of the time of hospitalization. Information about drug sensitivity or food allergy and any familial disease should be communicated to the surgeon, so as to avoid complications during hospitalisation. Because of the ever-present danger of cross-infection in the hospital, every effort should be made to make the period of hospitalisation as short as possible. If the infant is being breast-fed, the referring physician, in consultation with the surgeon, should make arrangements for the mother to continue breast-feeding the child while in hospital, or, if this is impossible, for her to pump her breasts at home and have the milk brought to the hospital each day. It is also the responsibility of the referring physician to check on the health of other members of the family, and to treat any infection with which the patient may come in contact. EMERGENCY SURGERY IN OLDER CHILDREN
Obviously, in an emergency situation, there is little or no time for other than the essential preparation of the ill child for the operation. Most of this will be the responsibility of the surgeon himself. The referring physician, however, should introduce the surgeon to the child and to the parents. The child should be told that he is going to have an operation, and that the surgeon will fix the pain or trouble and will make him well again. To the parents, anxious and sometimes almost terrified, the referring physician should briefly outline the situation, and reassure them that the surgeon has handled this sort of illness many times before, and can be relied upon to treat the child to the best of his ability. The referring physician should tell the surgeon essential information about the family, their conduct under previous stress, their worries and
COLIN C. FERGUSON
983
fears, so that when the surgeon talks to the parents, he may have this background of knowledge in reassuring them about the operation to be performed on their child. Their financial situation should be briefly outlined to the surgeon. Many parents in an emergency situation request private accommodation and special duty nurses, and state that expense is of no consideration. The referring physician, knowing the family's financial situation, can see to it that good care is provided, but not unnecessary care which will indebt the family far beyond their financial resources. Any allergies or sensitivities of the child should be noted on the chart. The immunisation to date may be of importance and should be carefully recorded. History of exposure to contagious disease should be determined, and, if the child has been exposed, arrangements should be made for him to be treated in isolation. When the child has been taken to the operating room, the parents should be told where they are to wait and how they will be informed about the operation and the post-operative progress of their child. If the hospital has a post-operative recovery room, the parents should be told in advance that their child will not immediately return to his bed. If the family circumstances do not permit the parents to wait during the operation, the referring physician and surgeon should arrange how the parents will be informed of the results of the operation, and who will do it. Acute laryngo-tracheo-bronchitis constitutes a possible surgical emergency deserving special consideration. This disease occurs most frequently in the winter months, and the respiratory difficulty often becomes greatest in the small hours of the night. If the physician, at the child's house, suspects that the child may require a tracheotomy, he should immediately notify the hospital to have all emergency equipment in readiness. He also should arrange for the surgeon to be at the hospital to meet the child on arrival. The readying of the child for the trip, and the drive through the cold night air, frequently aggravate the respiratory obstruction, so that a child, previously only moderately distressed, may arrive at the hospital cyanosed and desperately in need of tracheotomy. With the operating team in readiness, and the surgeon prepared, this lifesaving procedure can be immediately performed. ELECTIVE SURGERY IN OLDER CHILDREN
Children over four years of age who must have elective surgery can be helped both from a physical and particularly from an emotional or psychic aspect by careful pre-operative preparation. As mentioned before, with young children, the physical condition of the older child should be carefully evaluated and any deficiencies corrected before operation.
984
PREPARATION OF THE CHILD FOR SURGERY
Prugh 2 • 3 has reported that over one-third of children studied, showed some reaction to hospitalisation for either surgical or medical illness, and this reaction persisted for at least three months after discharge from hospital. In actual fact, the proportion of children showing psychic disturbance as a result of hospitalisation or surgery is likely higher than this figure, but minor post-operative behaviour problems may not be mentioned by the parents to their doctor. Much can be done to prevent these emotional problems by pre-operative preparation, and much of this is the responsibility of the referring physician or paediatrician. The child, after having been examined, and the need for elective surgery determined, should be removed from the doctor's office to be entertained by the nurse. The situation should then be clearly and concisely explained to the parents. This explanation must not be too detailed, since details will confuse or alarm the parents, but it should be sufficiently clear so that they can fully understand the need for surgery, and what is to be done. Doubtful, anxious and worried parents will communicate their fears to the child, and every effort must be taken to reassure the parents. The referring physician should instruct the parents in the psychological preparation of their child for hospitalisation. Most children's hospitals have booklets for parents, giving them advice on this, and it is the responsibility of the referring doctor to see that the parents receive this information. If the hospital does not have a booklet of this type, it is the responsibility of the physician to explain to the parents the hospital's admitting routine, the time for admission, the type of accommodation available, the articles of clothing to be taken to the hospital, the visiting hours, and so forth, and he should invite the parents to ask him any questions they might have. If the operation is to be performed within a few days of the office visit, the older child can be told by the doctor that the operation is to be performed. If it is to be delayed for several weeks, the child should not be told of the proposed operation until a few days in advance of hospitalisation. This should be done by the parents. Under no circumstances should the child not be told that he is going to the hospital. Certainly he should not be lied to and told that he is going to a circus or for some other special treat. Fear of the unknown is prominent in anyone, and children are no exception. Usually a careful, calm explanation by the parents or the doctor of the necessity for hospitalisation and what it involves will benefit the child more than any amount of bribery or cajolery. At the Children's Hospital in Winnipeg, every Saturday morning, a motion picture film is shown. * The parents and their child (over four
* L. E. Hackworth: A True Story about Hospitals. Children's Hospital, Los Angeles. Calif.
COLIN C. FERGUSON
985
years of age) are invited to the hospital on the Saturday of the week before the scheduled operation. They are taken on a brief tour of the hospital, including the admitting office and the wards, and are shown the playrooms, the waiting rooms and the cafeteria. Any questions they have about the admitting routine, visiting hours, and so on, are answered by the staff nurse in charge of the tour. They are then shown the motion picture film, which clearly outlines what will be done for the child after his arrival at the hospital. Any further questions are answered, the parents are served coffee, and the children are given a dish of ice-cream. Although not all parents take the opportunity of seeing this film, it is our definite impression that those families who do, benefit greatly. Their child frequently arrives at the hospital for admission almost in anticipation of the experience, rather than worried and fearful of having to face the unknown. Colouring books or comics which describe the hospital and its routines are useful, but care must be taken that these outline the methods used in the hospital to which the child is to be admitted, because serious discrepancies between those described in the books and those of the hospital may confuse, rather than reassure, the child. Playing games of nurse or doctor at home before hospitalisation may also help in the pre-operative preparation of the child, but the success of these games depends almost entirely on the time available to the parents and their intelligence in making the games worth while. A neighbour child, allowed to participate in the game, telling stories of needles, enemas and other unpleasant procedures, will in a few minutes undo any good that the games might otherwise have accomplished. Under no circumstances should the referring doctor misinform the parents or the child with the hope of thus reassuring them. To mislead them that the child will not receive any needles, will not have any discomfort, that the mother can stay all night with her child, and that the anaesthetic will be given in the child's own room, when the hospital has not the facilities to carry out these promises, will lead to distrust and increased anxiety, rather than to reassurance. Above all else, a kindly manner, a common-sense truthful approach, and a clear and unhurried explanation of the need for surgery will be of great benefit to the child and to the parents in avoiding post-operative emotional upsets. DISCUSSION
Most of the foregoing has been written with the assumption that the child will be admitted either to a children's hospital or to a general hospital with a large paediatric service, and that the surgeon concerned will be at least familiar with, if not an expert in, the care of infants and children. If, however, these ideal circumstances are not available,
986
PREPARATION OF THE CHILD FOR SURGERY
then the referring physician or paediatrician must assume a far greater responsibili ty. Not only must he do what has already been outlined, but, in addition, he must assume the full pre-operative care of the infant or child. He must leave all the orders for medication, and may be required personally to manage the pre-operative fluid therapy if dehydration or electrolyte imbalance is present. Only after the child has been improved as much as is possible should the operation be performed. When the surgeon has had little or no experience in the care of diminutive patients, it is well for the referring paediatrician and the surgeon to decide, in advance of the operation, the exact responsibilities each will assume in the care of the baby. By this previously arranged division of responsibility, conflicting orders written by each doctor, and the resulting confusion to which this can lead, may thus be avoided. SUMMARY
The responsibility of the referring physician or paediatrician in the preparation of the infant or child for hospital has been reviewed. Since this varies greatly, depending upon the age of the child and upon whether the operation is urgent or elective, the subject matter has been considered under four headings: urgent surgery in the newborn; elective surgery in infants and small children; emergency surgery in older children; and elective surgery in older children. An attempt has been made to describe the preparation of the child (and of his parents) for surgery, both from the physical and emotional aspects. REFERENCES 1. Bishop, H. C.: Safe Transportation of Newborn Infants for Emergency Surgery. l.A.M.A., 165:1230, 1957. 2. Prugh, D. C.: Emotional Reactions to Surgery. The Non-operative Aspects of Pediatric Surgery. Report of the Twenty-seventh Ross Pediatric Research Conference. Columbus, Ohio, Ross Laboratories, 1958, p. 19. 3. Prugh, D. C., Staub, E. M., Sands, H. H., Kirschbaum, R. M., and Lenihan, E. A.' Study of the Emotional Reactions of Children and Families to Hospitalization and Illness. Am. J. Orthopsychiat., 23:70,1953. Children's Hospital Winnipeg, Manitoba Canada