Keeping emergency department visits anxiety-free—for children and parents

by Tom Ulrich on December 10, 2012

My son Zach, waiting for stitches in his chin in the Boston Children's ED. I'm not sure who was more anxious that night, him or us.

My wife and I have two, active, bouncy boys. Which means that we’ve made our share of visits to the Emergency Department here at Boston Children’s.

Twice it’s been for stitches. The first time was when my younger son, Zach, slipped in the bathtub and split his chin. The second time, his big brother, Owen, was climbing a boulder and slid down it on his face.

We don’t come to Boston Children’s just because I work here. And not because it’s the closest option for us (it isn’t). But because we know the boys will get top-notch care—it is a children’s hospital, after all.

What we didn’t realize, though, was how much more was going on during our visits to address the boys’ (and our) anxiety just as much as their lacerations.

Meet Baruch Krauss, MD. He’s been working in emergency medicine for 26 years, first in the adult setting, and since 1991 here at Boston Children’s. I first met Krauss after the WBUR CommonHealth Blog’s Rachel Zimmerman wrote and aired a story a few weeks ago about bringing her daughter here for stitches.

Baruch Krauss, MD

In her story, Zimmerman describes her surprise at seeing the emphasis Krauss put on making her family’s ED experience as pain- and anxiety-free as possible, beyond just administering Novocaine to her daughter’s wound before starting the stitches:

The entire experience was so profoundly different from any other medical encounter I’ve ever had as a mother. I understand that in an emergency, the priority is to fix the damage as fast and efficiently as possible. But Krauss offered such a higher level of care that I wanted to know more.

After learning of his focus on reducing anxiety and pain in children in the ED both with and without medication, she noted:

We’d won the ER lottery with this guy. It was like going in for your regular, ho-hum therapy session and finding Freud. This doctor chose my priority as his priority: to spare my child from pain.

I talked to Dr. Krauss a few days later to get a better sense of his technique in managing anxiety, much of which Zimmerman detailed in her CommonHealth piece. Like how in the first 10 seconds of walking into a room (about as long as it will take you to read this list) he:

  • assesses the family’s emotional state
  • looks for clues to the child’s interests
  • thinks about how to engage those interests to distract and calm her so that he can attend to her medical needs
  • figures out how to engage the parents, siblings, etc., so as to relieve their anxiety as well

“Children can’t mediate their anxiety like adults,” he tells me. “And they pick up on the anxiety of their parents and those around them. Regardless of the medical procedure, I need to take the time to assess anxiety and see how to increase a child’s focus.

“I have a bag of tricks and principles, but largely it’s improvisational,” he answers when I ask about how he applies his approach from child to child. “Each interaction is going to be different, and the same intervention won’t work with every child. But it should always look fluid.”

What he told me put my family’s experiences in the ED here in a new light. For instance, when we brought Zach for his chin, the attending gave him a mild sedative to keep him calm during the stitches. Since it was well after bedtime, my wife and I figured he’d conk right out.

“I need to…think about how I can minimize the trauma of that procedure so that child will still want to see the doctor in the future.” – Dr. Krauss

So we were a little annoyed when one of the nurses came in seemingly at random to give Zach a balloon. So instead of falling asleep, he looked up at the balloon the whole time.

 

Now I realize that the balloon wasn’t so random.

“By bringing him the balloon, she did a couple of things,” Krauss explains. “First, she shifted his attention away from his unfamiliar surroundings. Second, because he was looking up at the balloon, his head was tilted back, making it easier for the attending to place the stitches.” Smart.

Then there was the time we brought Owen in after his boulder incident. The ED attending that day, Eric Fleegler, MD, had me swab Novocaine in Owen’s cut. “Eric is one of many emergency doctors that I’ve trained over the years to approach patients this way,” Krauss says. “He probably saw Owen looking to you to know that things were OK, and that you wanted to help take care of him in some way.”

I heard echoes of Krauss’s words (as well as those of one of his colleagues, Neil Schechter, MD, about whom I wrote some months ago) when I read the American Academy of Pediatrics’ recent report on pain and anxiety management in emergency rooms. Things like family involvement in care, appropriate preparation and education for children and parents about what’s going on and using simple distractions—they all resonated with the goal Krauss described in our conversation when it comes to providing emergency care: delivering a painless, non-traumatic experience for patients and families.

“You’re shaping a child’s health care experience,” he said. “As a doctor, I need to look beyond the immediate procedure and think about how I can minimize the trauma of that procedure so that child will still want to see the doctor in the future.”

Kids aren’t just small adults—they benefit from special skill and care provided by staff with pediatric expertise. If your child needs emergency care close to your home, consider going to one of Boston Children’s community hospital partners north, south and west of Boston:

  • Beverly Hospital: 85 Herrick Street, Beverly – 978-922-3000
  • Norwood Hospital: 800 Washington Street, Norwood – 781-769-4000
  • South Shore Hospital 55 Fogg Road, South Weymouth -781-624-8000
  • Winchester Hospital 41 Highland Avenue, Winchester – 781-729-9000

At our conveniently located community hospital partners, Boston Children’s physicians are on-site to care for your child. The doctor is in constant communication with Boston Children’s ED, as well as our specialists and inpatient unit. If your child needs care at our main campus in Boston, our renowned Critical Care Transport Team’s uniquely equipped ambulance is on hand to bring your child to our Boston location.

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