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– Being in the hospital can be frightening and stressful for a child, but medical play can make a real difference in their experience. Hi, I’m Tonia Caruso. Welcome to this UPMC HealthBeat Podcast. And joining us right now is Kelley Gavel. She is a certified child life specialist in the pediatric intensive care unit at UPMC Children’s Hospital. Thank you so much for joining us.
– Thank you so much for having us and thinking of our team.
– Well, this is such an interesting topic. And I know for so many parents it’s an important thing that they may not even think about heading into something. You work in the pediatric ICU, so you see very ill children.
– Yes.
– How does medical play play into that? And, I guess, first, let’s define for folks what medical play is.
– Yeah.
– So, first we’ll talk about the PICU, so pediatric ICU. These kids need the most intense care. It’s in the name. A lot of these kids come from really terrible traumas. So, think car crashes, bicycle accidents. Medical play can really help deconstruct what is going on in their head. They may have had a ton of medicine, you know, pumped through their system to get their body stable after this. Medical play can help put the pieces back together. “Why is my arm like this? Why is my leg hurting so much? What is on my head? Where did my hair go?” A lot of this can help put those pieces together for a child. However, true medical play, with a typical, healthy, developing child, should be fun, therapeutic, and child-directed. So, what we do in the ICU is I look at the child that I’m working with. I figure out, OK, their medication, or their sedation, so that sleepy medicine that makes them really relaxed, and they’re not moving, once that’s all lifted, OK, what do they remember? What might those common misconceptions be? How can we help that child cope immediately in the hospital? So, we first like to orient kids to place, time, what day it is, etc., and then answer those misconceptions. Some kids might not be able to communicate right away. So, they may still have that breathing tube in their mouth. So, we may need to get them a communication board first. I would ask those prompting questions. “Are you wondering why your arm’s up like this?” “Are you wondering why your foot feels like that?” And most kids are, “Yes,” or they’re blinking twice for yes. So, at first just might be conversational. Let’s just help you zone in to the place and time and where you are right now.
– What would you say is the baseline for assessing a child’s fears and concerns? And, then, how do you really go about starting to do that and then to address them?
– Yeah. So a lot of it is working with the medical team and seeing, hmm, what is going on in their brain? Did anything happen? Do they have a concussion or a TBI, traumatic brain injury? Also, talking with the parents. So, maybe a kid really loves Spider-Man. OK, let’s put Spider-Man in a cast and make Spider-Man look exactly like what the child is experiencing. So, if the child has, you know, a wrap around their head from maybe some brain surgery, Spider-Man gets that. So, it’s something using the kids’ strengths and interests beforehand and bringing it into the hospital and saying, “Oh, look, Spider-Man also has this.” We want to assess where was the child beforehand? What happened? And did anything in that accident, or trauma, or injury, whatever that might be, did anything impact that child’s development? So, it really is a multidisciplinary approach, seeing how they’re responding, etc. Making sure that they’re at that same developmental level, and if not, taking those steps back and saying, OK, let’s see how we can do this. It might be pictures, it might be hand over hand. It might just be talking through this. It really does look different for every child.
– And, so, tell me about some of the work that you do in getting a child ready for a procedure or explaining to them what it is. And you’ve brought many friends along.
– Yes. I have.
– To help you illustrate this.
– I have. So, one thing, we had a patient recently who came in for a procedure, and she was going to wake up with something different on her belly. So, she was going to have a stoma, and that she was going to need to use these bags. So, oftentimes, we’ll bring things in, and medical play is really supposed to be free and easy. But, you know, oftentimes, especially in the ICU, we need to do some education with it as well. So, either preparation or debriefing after a procedure. So, medical play in its true sense, there are no rules. However, in the hospital, you do want to guide sometimes the conversation. So, that’s more guided medical play. So, I would bring this cute bear. Cute little bear. For those of you listening to the audio version, describe what this bear has.
– Yes.
– It is a little stuffed bear. It has a stoma. It’s actually made out of model magic. And then we colored it.
– And what is a stoma?
– So, a stoma is basically an opening. So, this would be where poop would come out. And then this bag is where the poop would go. So, we have all different children’s books about how people go to the bathroom differently and things like that. But this would be an example of one of the things that we could do, and do the bag changes. And, then, free medical play would be bringing a stethoscope or the thing they look in your ears with the lights and allowing the child to maneuver all of this and construct a conversation that is child-driven. So, they might look at this flashlight but they’d be like, “Oh, it’s a drum.” And they might start tapping it. Oh, or, this is the bag. And they might start using, they might put beads, or they might put whatever they want in the bag. You’re right, it does, it collects stuff. It’s going to collect stuff that comes out of your body. So, we can guide those misconceptions. You know, you could turn this into an art project.
– Right.
– You know, you could use this for all sorts of different things. So, medical play is a way for a child to see things that are going on in their body or on their body, but do it in a really free manner that they can create and explore all of these pieces on their terms.
– Right. And, so, is play a really good way to express fear, concern, to communicate?
– Yes. Another example would be this. We’ll bring out my trach and G-tube friend. So, this bear was actually created by Tubie Friends. It is an organization we have a partnership with. And these are real medical equipment. You know, these are real devices that are sewn basically into the bears so that they don’t move. That does not happen in a child’s case. But in the instance of a bear that has stuffing, that is how it stays in place. But, bringing a bear in like this for a sibling. So, maybe their sibling on the ICU just got a trach and a G-tube. What we would do is meet them in a non-threatening place in the hospital. I would bring my trach and my G-tube bear with a bunch of other things. I would bring my stethoscope, or a real one. I might bring a play syringe, a real syringe. And, we might just talk about it. You know, I brought these things. Maybe I brought some paint and some bubble solution. We might do syringe painting, we might do syringe bubble blowing. What you would do, you would just suck up the bubble solution or the paint into the syringe, and then you can just squirt it.
– And it really is just to get them comfortable.
– Comfortable. Yes, exactly. And this bear might be there, they might look at it like, “Oh, you know, what’s going on with this bear?” And I would say, “What do you see on the bear? I think the bear’s really soft. He’s really good for a hug. Hmm. Like, what do you see?” And they’d say, “Oh, what’s this thing on his neck?” And I would say, “That’s a good question. Have you ever seen this before?” I always like to assess a child’s understanding. What do they think it is?
– Right.
– They might know.
– Right.
– And they say, “Oh, I actually think that’s the G-tube.”
– And, we were talking earlier. You said there are certain terms that can confuse children.
– Yes.
– And, you make a point of really using language to explain things. And, tell me a little bit about that.
– Yeah, so we always like to be truthful. We always like to call it what it is. So, if a kid is hearing that they’re getting an IV, they might be, “Oh, like I have ivy on my house. You know, someone, like, “A gardener just came by,” or like, “You know, my dad is trying to get the ivy off the house.” Like, “Why is there ivy?” Like, “How’d it grow on my brother?” They might be so confused. It’s like, “Hold on, we’re going to call it a straw.” A tracheostomy is an opening in your trachea. A trach here is, this is how someone is going to breathe. They’re going to use their trach here instead of their mouth. We like to call it what it is. A G-tube is helping get medicine right into someone’s stomach. We like to be honest with kids.
– Right.
– Because I’ve seen some parents, and out of the goodness of their heart, they make a nickname for whatever it is. It might be their cancer diagnosis, they might call it something else. And, that might be really confusing because another kid, you know, they might be playing up in the playroom, and they’re like, “I’m here to get my lilly injection.” They might be like, “Oh, my name’s Lily. What do you mean?” So, you don’t want to misname something because that can cause a lot of confusion. It’s always out of, usually, the goodness of someone’s heart. They don’t want to call it what it is, but call it what it is.
– So, then, what sort of conversations do you have with young patients when they are expressing fear?
– Always like to have it in a non-threatening way. And, I might just make a story up and be like, “You know what? Another kid, they were a little bit worried about moving units. You know, they didn’t know who was going to be up there.” Or, “You know, my friend down the hall was telling me earlier they’re afraid to walk right now. Is there anything that you’re afraid of right now?” Because I know sometimes, this whole place is a little scary. And, also, empathizing, you’re in a room full of strangers. People are touching your body in different places. It’s really uncomfortable. And, just stating that out loud: “Man, if I was here, this would make me uncomfortable. Is there anything that has made you uncomfortable here?” And just guiding that conversation.
– Right. And what does that opportunity provide them? And can you instantly, then, reassure them? What does that process typically look like?
– A lot of it is validation, and a lot of validation for the families, too. You would never imagine having these conversations with your 4-year-old in your wildest dreams. You know, it’s been pretty status quo for most of our kids until something happens, or a diagnosis happens, or a trauma happens, and then their world has changed. So, validating, “This is not where you plan on being on a Wednesday morning. Not at all. I cannot imagine how you’re feeling. I’m here to help you. What can I help you with?” Some kids want to know what movies we have on TV. Other kids want to know, “What floor am I on?” Sometimes, kids come in in such a rush, and sometimes they don’t remember everything. So, trying to orient them, “You’re on the fifth floor, you’re in room 502, my name is Kelley.” And trying to orient them that, “I am here to help you. It’s OK to be scared here. There are a bunch of strangers.” You know, kids are conditioned, “stranger danger,” you know, “Your body is your body. No one can touch your body without your consent.” You know, all of this stuff. And all of a sudden people are in here, you know, there’s stuff on your chest.
– Right.
– And it’s on your back. And you might be an older child, you might be 12 years old, but you have to wear a diaper. Or, a child that was learning how to be potty-trained is now back in diapers. All of this stuff is like, “Whoa, whoa, whoa, whoa.”
– Right.
– Validating it and kind of calling out that elephant in the room can be really helpful.
– Is there an age group that is particularly challenging? I mean, with younger kids, you can pull out stuffed animals, and Spider-Man, and he’s doing this, he’s doing that.
– Yeah.
– What does that look like when someone is 12 or 13 and going through something?
– Each age group kind of has its own challenges. So, for the infants, a lot of it is they just want to be with their trusting adult. So, however we can do that is going to be really beneficial. In the NICU, getting that skin-to-skin and being able to hug your baby. You know, you want to just physically touch them. You’re working on that attachment. Then, we have our toddlers who are, like, wild. And they’re trying, they’re like, “I want to do this.” And, “No!” And, no is their favorite word all of a sudden, and they want to run out of the place. Trying to contain them in a safe place, and you have all these lines. So, I mean, each age group really has their own challenge and difficulty. But, getting to know your kid. You might have a 4-year-old who has no problem. You know, they might act, you know, as if they’re 12 years old, but they are 4. But, then, you may also have a 12-year-old who regresses a little bit. There might be like bedwetting when they go home or something like that. Then you have your teenagers who are like, “I’m missing prom,” you know?
– Right.
– They might not have a care in the world about their diagnosis or the G-tube that they just got. They’re like, “No, I was supposed to take my driver’s license test yesterday, and now I’m here.”
– How important do you feel these conversations are, and how, ultimately, medical play plays into a child’s experience and successful treatment?
– So, everything is about positive coping. So, what we really like to instill in children is that they can do this. That we believe in them, that they can do this dressing change. They can have their port access. They can, you know, get their central line dressing cleaned. Or, maybe something’s coming out that they’ve had for a really long time. Being truthful and having an open-ended conversation is really, really helpful. It really depends on what is happening. So, if a child is approaching the end of their treatment, what is that transition going to look like? Having those conversations at home, you know, “You’re going in for your last ‘X’ treatment. How are you feeling about it?” You know, and the parents can model that vulnerability. You know, like, “I’m a little nervous, you know, that we’re not going to be at the hospital every week. Are you feeling nervous about anything? How would you like to say goodbye, or see you soon to your team?” We see that a lot in the ICU. People get really comfortable with our nurses and our staff being there all the time. The doors are glass, so you can look out, and just wave, and ask people to come in. So, starting those transitional conversations can be really helpful. And modeling for kids. Because sometimes they don’t have the words, but looking to a trusted adult, whether that’s mom and dad, or a nurse that they know really well, respiratory, child life, whoever that is, you know, saying, “I’m really going to miss you when you go upstairs. I believe that you can have these coping skills when you go upstairs and when you go home, that you can do this.” It might be doing a trach change at home, and the parents have been learning for months, and months, and months, that they can do it. So, not only do we work with a kid on keeping their legs still, and tilting their head up, so that they have a good view of the site and all of that. But it’s also the parents, that they have learned the tools. And it’s a lot about self-efficacy. You know, “You can do this. We believe in you, but you have to believe in yourself, too.”
– Right. I can tell you absolutely love your job. What is your favorite thing about your job?
– It’s the best thing. Because you see kids come in, and it is absolutely crisis time, traumatic time. Oh my gosh. And now they’re walking out of here, or wheeling on out out of here. And it is remarkable.
– Right.
– It’s the best part.
– And you’ve certainly played an important part in that recovery and treatment. We thank you so much.
– Absolutely.
– For coming in and spending time with us today.
– Thank you.
– Some great information. We appreciate your time.
– Thank you so much for having me.
– You’re welcome. I’m Tonia Caruso. Thank you for joining us. This is UPMC HealthBeat.