Cast off

The possibility that being "frightened to death" might be more than a linguistic expression was the focus of a study conducted at the Schneider Children's Medical Center in Petah Tikva.

The study examined and measured the stress experienced by small children when having a cast removed. The trigger for the study was the tragic case of an 18 month-old toddler with a heart ailment who collapsed and died of heart failure, physicians believe, soon after a doctor sawed apart the cast for a broken bone and sent the child home with his parents.

"It happened several years ago," recalls Dr. Kalman Katz, a senior lecturer at the orthopedics department. "The child came in to have a cast removed. The procedure was uneventful. The medical staff and the parents shook hands and the parents headed for the elevator, where the child suddenly collapsed." Because the parents were religious, no autopsy was performed, but Dr. Katz claims that there is room to believe that the cause of death may have been triggered by an irregular heartbeat caused by anxiety. The child had suffered from a congenital heart ailment that affected the electrical functions in the heart muscle.

While dentists had already written about the connection between the sound of drills and anxiety in children, no professional research had yet been carried out on the possible jeopardy to heart patients during cast removal. Dr. Katz, together with doctors Rami Fogelman, Joseph Attias, Elhanan Bar-On, Avner Czieger, and Professor Michael Soudry decided to conduct an interdisciplinary study - bringing together not only orthopedic surgeons but also experts in cardiology, child psychiatry and audiology. The decibels registered by the saw used to remove the cast were equivalent to a scream. "There was general agreement that the din was probably a source of anxiety and that anxiety impacts on physiology - including an increased heart rate," noted Dr. Katz.

To test this, the behavior of twenty healthy children who had come in to have casts removed was monitored with ECG equipment. The study compared the heartbeats of ten children who were given earmuffs to dull the noise of the saw with ten children who did not have any protection from the noise. The findings indicated that the heartbeats of children exposed to the noise were 27.1% higher than normal, while children wearing earmuffs during the sawing experienced only an 11.1% rise in heart rate.

In April of this year, Dr. Katz presented the findings of the study at the annual meeting of the European Pediatric Orthopedic Society in Milan. It generated animated discussion among colleagues, who commented that they too had encountered children terrorized by the sight and the sound of the saw freeing the cast, though not necessarily that of a child having been "scared to death".

"One colleague said he no longer used a saw at all, but softened the cast in water. Another said he was developing a quiet saw'. There was awareness of the problem, but this is relatively recent - accompanying the development of pediatric orthopedics as a specialty, separate from general orthopedics," explains Dr. Katz. "Consequently orthopedic specialists have begun relating to young patients as persons with special needs. The most problematic are children up to the age of six or seven." A detailed report on the study is scheduled to appear in the U.S. Journal of Bone and Joint Surgery some time this year.

"I have always demonstrated on my own arm to young patients that it is not a cutting saw. The instrument merely oscillates right and left, not back and forth. But the movement is accompanied by a lot of noise," says Dr. Katz. He and his colleagues believe special care should be taken in treating children suffering from cardiomyopathy - a congenital condition of the heart muscle, and also other heart ailments. "It might be wise not only to use earmuffs but not to use saws at all in these cases," he advises. The odds that anxiety could be detrimental to the health of other children are slim, but Dr. Katz recommends earmuffs as good practice for healthy children, as well. At Schneider, the use of earmuffs during cast removal is now a regular practice.