In the summer of 2018, I was given the opportunity to shadow at the Granger Pediatric Emergency Department at Sparrow Hospital in Lansing, Michigan. Sparrow's pediatric department is different than many, for it is one of the only emergency rooms in mid-Michigan that is equipped and staffed to understand that children who are injured or ill need different medical and emotional attention than adults. In the emergency department, I was badged with "Medical Observer". I chose this path of shadowing because the emergency department has always been interesting to me with the many patients coming and going. Also, based on my experience observing the injuries and sicknesses of children and their extremely quick recoveries seems like an upside of working in the pediatric portion of the emergency department. During this time, I had the chance to assist in a clinical study with child life specialists (CLS) and physicians, as well as observing different traumas. My responsibility with CLS was to observe, assist in recording and analyzing data, and ultimately to learn the actions of children and what relieves their pain and anxiety the best.
During my time shadowing I watched the physicians and child life specialists care for the children. It was shocking how they used their techniques to completely change the mood in the room. One of the physicians I shadowed was my mother. Since my mother is the head of the pediatric emergency department at Sparrow Hospital, I have always been interested in medicine. I have watched her bring her work home to perfect her skills as well as her continuous effort to figure out diagnoses, which has helped me continue my drive to go into medicine. Without my experience this summer my ideas of medicine would still be broad, and I would not have been able to narrow down my possible future career options. Throughout my life I have always wanted a profession in the medical field, but my experience has led me into a desire to work in pediatrics.
Before working with CLS I had observed traumas, and it was amazing to watch the physicians get to work immediately and in a calm manner. When walking into the room it was almost always chaos at first with EMS trying to speak as fast as they can while explaining what was going on, but once the physician began their procedures it instantly alleviated the chaos in the room. The only job I had while observing the traumas was to give the doctors and nurses things that they needed while they were rushing such as towels, Emesis bags, sheets, gloves, etc. Observing these traumas and the quick thoughts and decisions of the physician helped me understand the pressure they feel on the everyday basis. I also gained tremendous respect for them, not only for the lives they save, but their continuous work ethic while remaining calm in life or death situations.
Working with the child life specialists, on the other hand, helped me to learn and understand their mission to help infants, children, youth, and families cope with their concerns and stress of injuries, illnesses, as well as treatments. Their way of doing so includes therapeutic play and educating them on certain things in order to reduce fear, anxiety, and pain. They do this by simply speaking to the children to cheer them up and using technology, such as iPads, to distract them during certain procedures.
During my time assisting these child life professionals, they researched a fairly new technological technique: virtual reality (VR) distraction. The purpose of this clinical study was to reduce the pain and anxiety for children in the emergency department by experimenting whether VR can decrease the pain and anxiety for children during routine procedures more effectively than the CLS can. For this study, the routine procedure chosen was IV placement. This has the potential to improve care delivery which would result in a better guardian and patient satisfaction.
Usually, when a child shows signs of anxiety and/or high levels of pain, the physician or nurse will contact CLS to assist in distracting the child during an IV placement. This is typically done through visual distraction, such as with the use of an iPad. The child can still see the nurses and the needle, and when this happens the child usually becomes increasingly anxious further increasing his/her pain perception. With VR, the child's vision is blocked by the headset, along with auditory block by headphones connected to the headset. It is thought that the more senses used in the distraction method, the less likely the patient will experience intense pain (Dahlquist, 2008).
When a child visits the emergency department they are already very frightened, and inadequate treatment and relief of pain during procedures can have potential negative effects on future pain tolerance. This study has potential to improve current pediatric treatment as well relieving the stress of the parents/guardians knowing their child is the closest they can be to pain free during their visit. Also, this study will increase the knowledge on implementation of VR distraction in the emergency department for future treatments and broader applications. Previous research shows reduction in self-reported pain using VR, however, there is few research on pain reduction using VR during an IV placement.
During this study, I was to observe, assist on collecting data, as well as assist on data analysis of the numbers of participants, surveys of the parent/guardians, and reasons for the visit itself. Unfortunately, I was not allowed to touch any patient at any time during a shift because of liability issues. Sparrow Hospital is still in the process of collecting data on pain distraction using VR.
Children are placed into the intervention group (VR distraction) or the standard care group (CLS distraction). For a sufficient amount of data, the aim is to get 60 patients between the ages of 5 and 12 years old who need an IV placement in the ED. The goal is for there to be 30 in the control group, and 30 in the VR group. Currently, the population is too small to know if the data is significant or not, therefore, the study is still in progress.
In the standard care group, a CLS will distract the child by showing a short video on an iPad, which is the current standard of care at Sparrow Hospital. In the intervention group, the patients will receive a VR headset and headphones that connect to the headset (Figure 1). This will provide complete blockage of sound and vision in order to distract the child visually and auditorily in the hopes of decreasing pain perception.
Pain was measured before, and after, the IV placement by asking each child to rate his/her level of pain using the Wong-Baker faces picture scale (Garra, 2010). This six-item ordinal face scale is commonly used in pediatric emergency departments in which the child chooses a face that represents how much pain they are in (Figure 2). A survey was also given to the parents/guardians of the children in both groups to record degree of pain they believed the child felt along with the degree of anxiety the parent felt during the IV placement. It is hypothesized that the intervention group will have lower self-reported pain after the IV placement than those in the standard care group.
While I was shadowing there were 27 children age 5-12 that contributed participated in the study. There was only 1 withdrawal to the study for unknown reasons which does not contribute to the 27 participants. The average age was 8.6 years, with 22% being male, and 78% being female. Sixteen children were part of the standard care group, and 11 children were part of the intervention group. Parents/guardians were to complete a post-distraction survey consisting of reasons for emergency department visit, degree of the child's pain during the IV placement, and the degree of anxiety that the parent felt during the IV placement. In the intervention group, 70% came in due to abdominal pain, nausea, vomiting, diarrhea, or dehydration; 20% came in due to difficulty breath, respiratory distress, or asthma; and 10% came in due to other reasons (Figure 3). The standard distraction group had the same categories of reasons for coming to the hospital, but different proportions. In this group, 80% came in due to abdominal pain, nausea, vomiting, diarrhea, or dehydration; 5% due to difficulty breathing, respiratory distress, or asthma; and the rest due to other reasons (Figure 4). If reason for visit did not fit into the two groups given, the parent/guardian was instructed to specify the reason.
The intervention group showed a mean pain of 4.36 before procedure and a 4.73 after procedure, while the standard care group showed a mean pain of 5.38 before procedure and a 4.56 mean pain after procedure. These numbers show no significant differences between the two groups. Because of the small sample size and the failure to reach the goal of 60 patients, the study is still ongoing. On average, 65 children undergo IV placements each month in the Sparrow Pediatric Emergency Department; therefore, it takes time to get a portion of these children to participate in the study.
Intravenous (IV) therapy is vital for the recovery of sick children. Whether that be to hydrate them intravenously, prep them for imaging, or medicate them while in pain. An IV is a short catheter that is placed into a vein, typically in the antecubital vein. In order to guide the tube through the skin, a thin metal needle is used, then removed once placed in the correct spot. This needle is what causes the uproar of the children and parents, because typically nobody wants to be poked with a needle, however, in most cases that is the only option for the child to progressively get better instead of worse. Conducting experiments using VR distraction during routine medical procedures has been a fairly new concept, especially in conjunction with CLS. Throughout my experience, the question was whether or not virtual reality alone was more effective than the techniques of child life specialists during routine procedures (IV placements) for pain reduction in children.
The International Association for the Study of Pain states that "Pain is always subjective. Each individual learns the application of the word through experiences related to injury in early life." This emphasizes the importance of experiences from painful stimuli, especially in childhood, to shape future responses. Inadequate treatment of pediatric pain can result in long-term negative effects (Young, 2005). Even very small procedures, like a finger prick, can cause fear in children, but interventions are rarely used to reduce distress among these patients (Young, 2005). Not only does pain in children cause long term effects, pain in neonates can do the same. Although they do not remember the pain, psychologically it can impair their pain perception. For example, infant boys who were circumcised without analgesia as neonates show higher pain responses to the 4 to 6-month immunizations compared to the infants who are uncircumcised (Young, 2005).
Children in the emergency room are already in distress prior to their knowledge of requiring an IV. This often endures an acutely aversive experience. Needle insertion has always been a very bothersome and frightening experience, especially for children. Something that can potentially scar them for life, and they can create a lopsided ethical view of the hospital itself. An obvious distraction for this has been by using CLS and having the children watch videos or cartoons on a television, iPad, or any other electronic device. However, it has been found that children receiving immunizations, for example, while being distracted by a cartoon only watched the cartoon for about two thirds of the procedure, therefore, they were aware of the other third of the procedure and the possible pain it can cause for them (Gold, 2006). Being able to see the needle increases the perception of pain, along with decreasing pain tolerance for future ED visits. Without CLS, however, the patient would be aware of the whole procedure, which could potentially cause more problems in the care of the patients in the pediatric emergency department. Not only would the child feel everything, but also it would take longer for the IV placement, along with more difficulties in future visits.
It was found that it is not important for CLS to be there in order for a higher success rate of IV placement. A study done comparing the effects of CLS on success rates of IV cannulation found that the success rate was 89.6% with CLS and 90.9% without CLS (Murag, 2017). Although the outcome of this study suggests that CLS intervention does not predict the outcomes of successful IV cannulation of children, the benefits of CLS are much more complex than just success rates of IV cannulations that many people are qualified to do. CLS represents psychological benefits, producing large impacts on the child's ability to handle pain along with increasing parent satisfactions of the procedure and environment their child was placed in. This is increasingly effective when the parents are more knowledgeable about the role of CLS, because they will know whether certain services are necessary or not for their child (LeBlanc, 2014). According to a study conducted by LeBlanc and her colleagues, there were few children who received a service from CLS that parents deemed unnecessary for the child. The psychological benefits from CLS for both the child and the parents during medical procedures are very important for the future of the child along with the satisfactory elements of the ED.
Child life specialists uses more than just imagery distraction techniques for distraction of pediatric patients. In a study conducted by Bandstra and her colleagues, 607 child life specialists were surveyed to determine their use of nonpharmacological strategies along with the perceived efficacy of the strategies. There were 30 techniques reported and the most reported CLS techniques include providing information and preparation for a certain procedure, comforting and reassurance, positive reinforcement, behavioral distraction, and therapeutic play, however, it depended on the situation for other techniques to be involved. Also, it was found that the majority of CLS report using these pain management services to at least 50% of their patients (Bandstra, 2008). There are also some strategies that are used least frequently. This can include virtual reality because of the little research that has been done with the effects it has on pain perception in children. The potential that VR has for decreased pain perception is the reason Sparrow Hospital is still in the process of researching it along with other hospitals and institutions.
Virtual Reality is identified to be a great tool for pain distraction not only for its ability to visually and auditorily block the situation, but also because it demands attention from the patient. The multi-sensory nature of the VR experience draws user away from the "real world" environment and into the make-believe "virtual world". Psychologically, children are more susceptible to fantastical thoughts because their brain is still developing. It is thought that VR distraction in children should be able to quickly and easily draw attention to the child during short procedures like intravenous cannulation, whether that be strictly for fluids, or before imagining. It could also assist on distracting the patient during blood drawing. At the Children's Hospital Los Angeles Department of Radiology, they used VR for IV placements before outpatient MRI or CT scans. It was found that the control group experienced a significant pain increase following the IV placement, whereas there was no change in pain for the VR group (Gold, 2006). These results emphasize the benefits of VR distraction along with suggesting its ability to attenuate the avoidance of routine procedures. Although VR may use more equipment than standard distractions, it suggests less effortful distractions and easier procedures because of the cooperation of the patient, along with changing the psychological state of the patient to ultimately elicit the least pain possible.
Virtual reality has not been thoroughly studied because of the cost of the devices, however, there are now commercially available and inexpensive VR devices that can attach to almost any smart phone, to make them readily available. The increase in cost-benefit creates more opportunities for studies to advance and fully understand the effectiveness of this distraction technique. If virtual reality distraction is statistically found to be an effective way to side track a patient from pain during IV placement, then it makes it easier for the doctors to continue their treatment, whether that be for hydrating the patients via fluids or placement prior to imagining scans.
Virtual reality distraction can also be potentially effective to completely eliminate routine intravenous procedural sedations for certain procedures. For example, it has been found in a Stanford University School of Medicine study that it is effective to use VR for adductor canal catheter (ACC) placement prior to a total knee arthroplasty (TKA). During the procedure, the patients using VR distraction were asked by the regional anesthesiologist if they were experiencing pain, and if so, whether they would like to receive pain medication (fentanyl or midazolam) intravenously (Pandya, 2017). Only 14% of VR patients requested fentanyl, in comparison to 86% of the non-VR group (Pandya, 2017). Midazolam requests were also lower in the VR group. Of the VR group, the one patient that requested pain medication, only received one dose, whereas, the non-VR group was given either fentanyl and midazolam together, or fentanyl alone at the discretion of the regional anesthesiologist. In this study, using VR shows the near elimination of the need for intravenous sedation to reduce pain as well as not increasing the procedural duration.
There are many further applications to VR. Not only is VR a potential distraction from physical pain, but it can also contribute to the decrease of psychological pain as well. For example, there has been an increase in focus on combat-related post-traumatic stress disorder (PTSD) therapies which has led to virtual reality exposure therapy (VRET). This is using a method that does not take the attention off pain, but it draws attention to the pain by simulating a situation to challenge the patient's anxiety. The idea is to improve control over the exposure in the session, prevent avoidance, and allow greater engagement with treatment (McLay, 2017). The study of PTSD patients with VR exposure is a new concept as well and needs more participants to contribute to the data. VRET for PTSD patients are currently used in approximately 60 sites, mostly at military bases and university centers, to work with combat-related PTSD patients.
Both CLS and VR distraction have been found to be effective in reducing a child's pain during routine procedures in medical contexts, but for most things in the medical field, there are pros and cons. When a CLS interacts with the child, the child is not distracted during the whole procedure. A video on a tablet can only keep the child distracted for so long, and they would still be able to fully understand what is going on. Also, some techniques that CLS use are not as effect as others. For example, distracting the child using an iPad versus simply informing and preparing the child for the procedure. Each one can be useful and effective, but it depends on the patient. Lastly, it can be time consuming for CLS to calm down a patient that has to receive an IV. However, because of the many techniques CLS has, some know which ones can work better for each situation. It is relatively easy to have access to CLS if they are working in the emergency department. Usually they are not very busy because pediatric emergency departments try to limit invasive procedures as much as possible, so IV placements are only done when completely necessary.
Virtual reality, on the other hand, is a fairly new distraction technique so there is not a lot of evidence of its effectiveness. It uses more equipment which can cost more money than the objects used by CLS. Also, if VR is used, there would be a limited number of headsets available and they would have to be moved around to each room. However, VR is a great option if CLS are unavailable for the distractions, and it is a good interactive distraction for the children undergoing the procedures. VR and CLS are both good techniques for pain distraction in children. They both do not have side effects, whereas if pain relievers were given, there would be.
My experience at Sparrow Hospital has furthered my knowledge of medicine, the routines of working in the emergency department, and the many procedural techniques the physicians and child life specialists have to choose from, especially in pediatrics. Working with CLS helped me to understand the anxiety some children feel when coming to the emergency department, whether that be from an illness or an injury. Their calming attitude in combination with certain techniques was shown to help decrease the anxiety the patients felt. CLS strive to create a better environment for the children and the parents/guardians, and during my time shadowing, they continued to think of different ways to do so, including the use of the VR distraction technique. Since the study of the effectiveness of VR distraction compared to CLS is still ongoing, it is a necessity to have more participants in order to conclude significance or not. Although what we have concluded thus far shows no increased effectiveness using VR, other studies conclude otherwise, which is why it is continued to be researched within hospitals and institutions. This research is fairly new, and with increased knowledge, it has the potential to enhance the medical care in pediatric emergency departments.