The note read, “Everything went smoothly. … We loved the teddy bear! Such a nice touch! We couldn’t be more pleased with our child’s surgery experience. Thank you!!”
A simple teddy bear, provided by the perioperative staff, eased the child’s anxiety about the surgery, in turn easing her parents’ anxiety and natural instinct to defend.
It is now a matter of settled science that great patient experience, for kids or adults, is strongly associated with better patient outcomes (e.g., lower rates of wound infection, less post-operative bleeding, fewer complications, better adherence to post-operative treatment). When we take care of the little things, like care experience, we end up preventing the big things (medical misadventures) by creating and nurturing a culture of continuous improvement and zero harm. So it should be no surprise the technical aspects of the child’s surgery went well, too.
It is often said in pediatric circles, children are not little adults. They often need different drugs, different dosages, different tests, different operations and different clinical work- flows and often respond differently to a clinical environment that would seem typical for an adult. Moreover, within the pediatrics field, the stage of physiologic development, often estimated as age, has profound implications for both diagnostic and therapeutic algorithms. These facts of pediatric pharmacology, physiology and behavioral science may be no more evident than in the field of pediatric anesthesiology.
Our pediatric perioperative team must manage variable pharmacology perioperatively and alleviate the fear of both patient and parent in a moment of greatest vulnerability, whether that is sedation for surgery or an imaging procedure (e.g., MRI). The entire perioperative care team are parents ourselves. Most of us have been on the other side of the table, handing over our ill, precious child to a nurse, physician or surgeon. So we practice with the My Child Rule. In other words, if it isn’t good enough for our children, it isn’t good enough for someone else’s child.
In our practice at WellStar, our pediatric perioperative team has been relentless in continuously improving the approach to pediatric surgery. Through a combination of improved pharmacology and applied behavioral science, we’ve been able to achieve better pain control, less nausea, less anxiety and faster recovery from both the anesthetic and the surgical procedure itself.
Sometimes improvement requires a multidisciplinary approach. For example, having detected during a pre-operative assessment the presence of bigeminy (normal heart beats alternating with abnormal heart beats), with help from my pediatric cardiology colleague Dr. Jeffrey Sacks, we were able to diagnose a side effect of excessive caffeine use with minimal testing and operative delay.
Young children often require sedation for selected imaging studies like magnetic resonance imaging (MRI) or electroencephalogram (EEG) for the treating physician to obtain enough high-resolution information to advance the diagnosis or treatment. Dr. David Pae, my WellStar Medical Group Pediatric Anesthesiology colleague, used dexmedetomidine (an IV anesthetic) because it least affects the child’s EEG signals. But the real intervention may have been one of our pediatric nurses comforting the child in the stretcher during the EEG. The sense of teamwork and dedication to the children and their patients fills our work with meaning and ourselves with pride.
We have become deliberate in standardizing our efforts to reduce patient and parent anxiety. Another colleague, Dr. Akiko Ando, created a standardized workflow of (a) providing the child a mild preoperative sedative, (b) enabling the parents to witness the child’s journey to the OR, and (c) providing the parents timely and frequent updates during the procedure.
Moreover, we address pain management with non-pharmacologic approaches, including nerve blocks administered after the children are asleep. This not only reduces the amount of opioids we use, but often the children wake up with no pain at all. We have administered more than 900 nerve blocks in our practice, often enabling the child to go home with zero pain, lasting days.
Our faith in standardization of perioperative care notwithstanding, we simultaneously practice personalized care. We use all of the resources we need to provide a special experience for each child, including Child Life Services, pediatric nursing, state-of-the-art ultrasound equipment for nerve blocks and, for better or worse, computer tablets in the pre- operative holding area to distract the kids from the uncertainty of the procedure.
A recent parent commented, “Everyone was excellent on this day [of surgery]. … It felt as if my daughter and I were the only ones in the world who mattered that day!!”
When I look down and see a child that I am caring for, I see one of my own children. I tell the parents that my job is to care for their child as if they were my own.
Pediatric anesthesiology is a wonderful amalgam of pharmacology, behavioral science and highly reliable clinical workflows to keep children safe, calm and able to recover quickly. I know of no other professional life as fulfilling and rewarding.
Kent Stewart, M.D.
Dr. Stewart is the Director of Pediatric Anesthesiology for WellStar Medical Group (WMG). He trained at Georgetown University (residency and chief residency), Emory University and Egleston Hospital (pediatric anesthesiology fellowship), and University of North Carolina (medical simulation fellowship). He served for nine years as attending physician at Emory’s Egleston Hospital prior to joining WMG in 2014. He has received recognition from numerous entities for excellence in pediatric anesthesiology care, including The Joint Commission.
