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Dr. Gary Walco: Improving Pain Management

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Dialing Down the Pain

Dr. Gary Walco is on a mission to make every child’s experience at the hospital as painless as possible. Starting now.

Jackson Forebaugh and Taracita Brown Fall 2011 Connection

Needle sticks and blood draws meant pain and panic for cancer survivor Jackson Forebaugh, now 7. Pain control strategies, like numbing cream and arm positioning tips, make trips to the lab easier for Jackson and his parents – and for phlebotomists like Taracita Brown.

Before he even learned to walk, Jackson Forebaugh learned to fight cancer. Diagnosed with a rare, aggressive kidney tumor when he was 15 months old, Jackson endured surgery, radiation and seven grueling months of chemotherapy. He lost a kidney. But he beat cancer.

Jackson, now 7, is a long-term cancer survivor and a medical care veteran. But that doesn’t make it any easier to face needles.

During inpatient cancer treatment at Seattle Children’s, Jackson’s care team used numbing cream before inserting intravenous lines. But when he returned for outpatient follow-up care, Jackson learned the hard way that needle sticks can hurt. Trips to the lab for blood draws became tense events as his parents struggled to restrain their bucking, crying child.

“It’s hard to watch your child panic because he knows that pain is coming,” says his mom, Kelly. She knew that less painful needle procedures were the standard of care in some areas of the hospital. Why, she wondered, should blood draws have to hurt so much?

Dr. Gary Walco has an answer: They shouldn’t. Ever.

Walco, director of Children’s Pain Medicine program, is on a mission to make every hospital experience as painless as possible for every child. Achieving this goal, he says, requires nothing short of transforming the culture of pain.

Pain matters

Lisa Peters and Gary Walco Fall 2011 Connection

Advanced practice nurse Lisa Peters and Dr. Gary Walco are leading the effort to eliminate unnecessary pain throughout Seattle Children's.

As recently as 35 years ago, infants and very young children were rarely treated for pain because most doctors thought they did not experience it, notes Walco. Research has since toppled that belief.

“We know children feel pain, and we know how to treat it with precision and efficacy,” says Walco. “We also know that when pain is poorly treated, children can become more and more sensitive to it.”

But too often pain still goes untreated, even at the world’s best pediatric hospitals. Changing that is crucial because the physical and psychological consequences of pain – chronic or fleeting, severe or small – can last a lifetime.

“People at Children’s are committed to eliminating needless suffering,” says Walco, “but we need hospitalwide systems to make sure it always happens. When the culture is transformed, everyone – from clinicians to security guards to administrators – will understand that taking away needless suffering is part of their job, and each of us will have the tools to do our part.”

How to change a culture

Children’s has the essential ingredients to successfully change the way we respond to pain.

We have the know-how: Our interdisciplinary Pain Medicine program is one of the top in the nation, and our own pain management experts know the best and safest ways to prevent and treat pain.

We have Pain Champions, a network of nurses, physicians, administrators, child life specialists, parents and others who share information and model best practices to ease children’s suffering.

And we are committed to Continuous Performance Improvement (CPI), a way of assessing how we work, testing new ideas and making incremental improvements. This year, Children’s launched a series of pain-focused workshops, bringing people together to brainstorm, design and test-run changes that are yielding new standards to improve how everyone here cares for pain.

“The world is watching us,” says Lisa Peters, a nurse who specializes in pain issues and partners with Walco on the pain initiative. “When we present our progress and plans at international conferences, people listen.” What happens here will likely be a model for transforming the culture of pain elsewhere, she predicts.

Less pain after surgery

Shellie Stockfish and Jeff Avansino Fall 2011 Connection

Clinic nurse Shellie Stockfish and general surgeon Dr. Jeff Avansino led efforts to head off pain after hernia surgery. “The goal is to discuss pain control with families before surgery day,” says Avansino.

Thanks to one CPI workshop, Children’s is making crucial changes to pain management after surgery, starting with children who come here for hernia repair. Rather than talking about pain on the day of surgery or during a postoperative call with a worried parent, our surgeons now consistently discuss it during pre-operative visits. This partnership with parents prepares them to recognize and control their children’s pain after surgery.

By the time a child arrives at Children’s for outpatient hernia surgery, the family has a pain plan in hand and medications ready to take home. They understand how to recognize pain, even in a child too young to describe it.

Asking surgeons to be responsible for talking about pain at the preoperative visit “has revolutionized the pain experience for hernia patients,” says Dr. Jeff Avansino, a surgeon who co-led the CPI workshop with nurse Shellie Stockfish.

The change sparked something bigger, Stockfish adds. “I find myself talking with families more often about pain, and not just with hernia surgery,” she says. “A new awareness has permeated the department.”

“We’re scientists and our work is data-driven,” adds Avansino. “Our data show that what we’re doing makes a difference, and that will help the protocol spread to other outpatient surgeries and other areas of the hospital.”

Less painful needle sticks? Yup!

Eileen Klein Fall 2011 Connection

“There's always one more thing you can do to make a child more comfortable,” says Dr. Eileen Klein, an emergency room doctor and Pain Champion.

“One immunization is all it takes for a young child to associate needles with pain, and many people never outgrow the fear,” says Walco. “At least 10% of adults in the U.S. avoid medical care because they still fear needles – we can prevent that simply by paying attention to needle pain and distress.”

During last fall’s employee flu immunization drive, Emergency Department physician Dr. Eileen Klein and other Pain Champions fanned out across the hospital to deliver a message about needle pain. In hallways, at meetings and in the cafeteria, the champions pressed packets of numbing cream into their co-workers’ hands and urged them to try it when they got flu shots. They also gave out flyers with tips on coping strategies and arm positions to help reduce the “ouch” factor.

Many employees were relieved to discover that shots can hurt less – exactly the message the Pain Champions were trying to drive home.

“When we make even seemingly small pain — like needle pain — a priority, we’ll be less likely to tolerate more significant pain.”

Dr. Gary Walco

“If the numbing medication and the other strategies improved the immunization experience for our employees,” Klein reasons, “they might use them with patients or advocate for their use during shots, blood draws or other needle sticks.”

“Needle pain is real pain,” adds Walco. “When we make even seemingly small pain a priority, we’ll be less likely to tolerate more significant pain.”

Families: part of the solution

Patients and families are helping to eliminate unnecessary pain at Children’s.

“Children’s does so much to make sure the hospital isn’t a scary place for kids,” says Kelly Forebaugh, who is part of a family advisory council on how pain affects kids. “Making sure things hurt as little as possible will vastly improve the experience for families.”

It’s working for her son. During an emergency admission to Children’s last summer, Jackson got numbing medication and barely noticed the needle. It’s heartening because Jackson will be getting needle sticks for years to come. His parents will make sure he gets pain relief every time.

Gift Helps Bring International Meeting Back to Seattle

Constance Eddy Fall 2011 Connection

“My mother had a talent for alleviating pain,” says Constance “Tantsie” Eddy (second from right) with her parents, Dan and Mary Tarcea, and her brother, Bob Tarcea, circa 1974.

The world’s first symposium to focus on understanding and easing children’s pain was hosted by two Seattle Children’s physicians in 1988, when the field of pediatric pain management was still in its infancy. Just a decade earlier, conventional wisdom held that infants and babies did not experience pain. By the late 1980s, however, a body of research was confirming that even the youngest child can feel pain.

That initial symposium helped foster an international pediatric pain movement, with Seattle Children’s at its center.

Pediatric pain experts have gathered every three years since, and the meetings have grown each time. The 10th International Symposium on Pediatric Pain in 2015 will bring the meeting back to Seattle.

The Dan and Mary Tarcea Endowed Fund in Pain Management will help support the symposium. Constance “Tantsie” Eddy and her husband John Eddy II created the endowment to honor her late parents. They see the meeting as a way to leverage their investment in pain medicine.

“The researchers and educators who come to Seattle will take what they learn back to their own institutions and their own countries,” says Tantsie Eddy. “The work shared here will help children around the world.”

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