Medical procedures can be scary for patients of any age. For children, they can be terrifying.


One 60-year-old Spokane man remembers, as a child, screaming in total fear while being wheeled down a hospital corridor on his way to a surgery he didnt understand. Even as recently as 20 years ago, infants and teens often would undergo two separate spinal surgeries and spend six months in the hospital while being confined to a full-body cast.


Thats all changed drastically, and the art and science of helping young people prepare for and deal with surgery continues to evolve, health-care providers here say.


Now, says Charles Young, administrator of Shriners Hospitals for Children-Spokane, young spinal-surgery patients go home in five days. Hospitals also use a host of strategies, ranging from distraction to recreation to deep breathing techniques, to make surgery less stressful and painful.


We have great medications today, but we cant take all the pain away or theyd be in a coma, says Tomie Zuchetto, recreational therapy manager at Shriners here.


Reducing stress and pain levels for children both before and after surgeries is becoming so important that Zuchetto and three other certified therapists work full time on that task at the Spokane hospital. At Sacred Heart Medical Center, the pediatric intensive care unit, the emergency department, the regular pediatric department, and the oncology unit each has a full-time pediatric specialist trained in distraction techniques, says Krista Robak, child-life specialist in that hospitals oncology unit.


Whether theyre called diversionary therapy, recreational therapy, distraction techniques, or non-medicinal pain therapy, such efforts have a goal of preparing children for an operation and supplying them with tools to help offset the inevitable pain that follows.


Shriners and Sacred Heart both use a variety of techniques such as progressive relaxation, guided imagery, deep breathing, use of soothing music, and even the distractions of playing video games, to calm young patients and mitigate stress and pain.


Weve found that the mind can basically only focus on one thing, and pain sensations can be decreased through these methods, says Robak. She admits that the efforts arent always successful, and that some patients remain combative with their bodies.


Knowledge is comfort


In about the last six years, the theory that children dont need to know about an upcoming operation has shifted dramatically, says Zuchetto.


Previously, we didnt educate the kids on the procedures, she says. Now we do a lot of teaching about surgeries to help them understand what is happening and how they can prepare for it. We also teach them basic things such as what the operating room will look like, about the anesthesia mask they will wear, and about waking up with a cast on their body.


Children, says Young, need that kind of information maybe more than adults do.


What seems very basic to an adult may seem frightening to young kids who have nothing to relate this experience to, he says.


Parents also should be included in the training process, says Robak.


Sometimes its just as important to comfort the parents to keep the children from picking up the anxiety of the parents, she says.


Although ways to prepare children for surgeries are similar at various hospitals, the time allowed for that preparation can vary greatly from one facility to the next, says Zuchetto. At Shriners, because of the need to be more efficient with funds, young patients no longer are asked to arrive at the hospital one to two days before a surgery, as they had been in the past, Zuchetto says.


Some kids now come in the morning of a surgery, and others come in the day before for some education, then spend the night at home before coming in for the operation, she says.


Robak says a lot of kids at Sacred Heart oncology come in only five to 10 minutes before their procedure to learn stress and pain management practices. Whether dealing with youngsters facing outpatient or inpatient procedures, It would be ideal if I could spend a half-hour with them before their procedure, she says.


Music, relaxation helps


Zuchetto says she and the other three therapists who work out of Shriners recreational department use forms of music or sound, such as ocean sounds or Native American flute music, in most of their relaxation procedures because it has been proven to slow down the heart rate.


Teens who prefer rock `n roll are encouraged, prior to a surgery, to listen to a favorite artist and select a tune to listen to after the procedure that has a slower beat, she says.


Shriners personnel often work for an hour with patients and family members prior to surgery, teaching them about ways they can combat post-surgerical pain, and routinely try to visit patients in the critical period soon after the operation. The sooner the pain-relief techniques are implemented after a surgery, the better, Zuchetto says.


Once the pain reaches a certain level its hard to get it back under control, she says. Once children get anxious about pain, it gets worse and worse.


A technique called progressive relaxation, in which, while taking deep, steady breaths, the patient relaxes one muscle at a time until he or she reaches a point of total relaxation, often is used with teenagers. If employed after surgery, that technique can relax the muscles near the point of surgery and lessen the pain considerably, Zuchetto says.


Another technique targeted more toward youngsters ages five to 10 is called guided imagery. With it, the child is encouraged to use his or her imagination, by applying the senses of sight, feeling, smelling, and hearing, to transport themselves mentally to a favorite imaginary place of comfort and serenity.


Once all four of those senses are involved, the mind can actually trick the body into being there, taking the patients mind away from the pain, says Zuchetto.


The simplest method she employs, in which children learn to relax by repeatedly taking long, slow breaths, is deep breathing.


Robak says Sacred Heart uses distraction techniques with post-surgical younger children in the hospitals oncology unit. Those techniques include the blowing of bubbles through wands, storytelling, use of puppets, and reading pop-up books.


The Starlight Starbright Foundation, of Redmond, Wash., boosted Shriners non-medicinal pain mitigation efforts by donating about a half-dozen portable television monitors designed for playing video games and watching movies on tape. The sets, which are built to extend over a patients bed, are very popular, and entertain many patients while distracting their focus away from their pain, Zuchetto says. Sometimes thats all they need for a diversion, she says.


Doll therapy is another popular technique employed at Shriners for children about age four to 12, which includes roughly half of all the children that come through the unit where Zuchetto and the other three therapists work.


As part of an education process, a patient is given a one-foot tall, cloth doll, made by hospital volunteers, and is asked to be the doctor for that doll, which, figuratively, will be undergoing the same surgical procedure the child faces. By applying to the doll an anesthesia mask, blood pressure cuff, and other instruments that might cause fear in a child, some anxiety is abated, Zuchetto says.


When applicable, the child puts on a doll a cast, made of identical gauze and plaster ingredients as the cast to be used on a patient. The child even can take the doll to surgery, and, when he or she return to the hospital later to have a cast removed, a technician can first remove the cast from the doll, she says.


Part of the education often provided for children at Shriners is a briefing about the vibrating saw used to remove casts. The children are taught that the saw, which can be frighteningly loud, will stop when it comes in contact with the skin, and wont cause a cut. Zuchetto says children often are heard giggling from the vibration of the saw, and not screaming.


She says a similar education technique is employed with the removal of pins that can be nailed or screwed into the bone of a patient to stabilize a fracture. It looks scary and like it should hurt, but its not very painful, says Zuchetto.


Only within the last year has Shriners adopted a comfort position technique for blood draws taken from its youngest patients. Without restraining the child, a parent is asked to hug the child very tight while the blood is drawn, Zuchetto says. Many youngsters are required to have multiple blood draws during their stay in a hospital, and the comfort position technique makes them not so traumatic, she says.