Despite volumes of evidence that doctors undervalue the pain that hospitalized children feel, a quiet transformation is taking place at the Johns Hopkins Children's Center. There, doctors are starting to give some youngsters the power to control their pain.
In the era of just-say-no, anesthesiologists are starting to take a different view toward narcotic drugs like morphine when it comes to eliminating the post-surgical pain that can turn a child's hospital stay into a nightmare.
Quinton Carter, an 8-year-old boy who had a portion of his esophagus surgically removed last week, knows exactly what to do whenever pain starts to creep into his consciousness. He simply picks up a control panel that's about the size of two pocket calculators, and pushes a button that delivers a small amount of narcotic pain reliever to his bloodstream.
Earlier this week, Dr. Myron Yaster, chief of the pediatric pain service at the Children's Center, distracted Quinton from a Bugs Bunny cartoon and asked the boy to make a simple calculation. On a 10-point scale in which 10 was the most intolerable pain he could imagine, how would he rate his pain?
"Zero," Quinton said in the blink of an eye.
Just a few years ago, doctors started introducing their adult surgery patients to patient-controlled analgesia. It gives patients the ability to ease their pain before it reaches searing proportions. Medication arrives by means of an intravenous tube or a catheter that delivers drug to the area next to the spinal column.
Doctors maintain control as well. By punching in a few commands, doctors keep patients from dosing themselves at too frequent intervals. They also command the pump to deliver a minimum dosage each hour, ensuring that the child stays medicated while asleep.
The device has been a hit with adults, but Dr. Yaster said many doctors feared that children were incapable of operating the device. As the theory went, children simply couldn't be trusted to operate the control panel competently. They couldn't mentally associate the act of pushing a button with getting a desired effect like pain relief.
Nonsense, said Dr. Yaster, who last year embarked on a three-year plan to improve the quality of pain management at the Children's Center.
"If a child is able to play Nintendo, they usually can do patient-controlled analgesia," Dr. Yaster said. "Pushing a button to bring an effect is something kids don't have to be taught to do."
These days, post-surgery patients over the age of 5 or 6 are given the pump when regular pain relief is deemed necessary. And gradually, doctors are starting to equip even younger children -- but instructing their parents to operate the control.
Dr. Yaster laments that handling a child's pain has been a cumbersome affair, full of bureaucratic pitfalls that had nurses quenching pain once it flared rather than preventing it from ever reaching serious proportions.
"You'd have to tell the nurse you hurt," he said. "The nurse would have to believe you were in pain. Then the nurse would have to go to the order sheet, and you'd have to hope that the right drug was picked. The nurse would have to find another nurse who had keys to the narcotics cabinet."
After signing forms, the nurse would return with a needle.
The pump eliminates a cruel Catch-22 that can emerge when children must depend on doctors and nurses to bring medication, Dr. Yaster said. Professionals are often heard telling children: "No, you can't be in pain: it says here the medicine comes every four hours. How is it possible you can have pain within the interval?"
The pump is also helping children suffering from cancer and sickle cell anemia get through painful episodes. Tanya Parrish, a 14-year-old leukemia patient from Middle River, said she wouldn't be able to eat or drink without prompt pain relief.
The chemotherapy given in conjunction with a bone marrow transplant had destroyed the cells lining her mouth and throat, producing searing pain. "Just the air getting to it hurt real bad," she said.
Swallowing her pride came easy.
"At first, I wasn't too sure I was going to push it," she said, displaying the control panel. "But when I saw how bad it could get, I pushed it."