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The Journal of Emergency Medicine, Vol. 17, No. 1, pp. 53–56, 1999 Copyright © 1999 Elsevier Science Inc. Printed in the USA. All rights reserved 0736-4679/99 $–see front matter PII S0736-4679(98)00114-0 Clinical Communications HYPNOSIS FOR PEDIATRIC FRACTURE REDUCTION Kenneth V. Iserson, MD, MBA Arizona Bioethics Programs and Section of Emergency Medicine, University of Arizona College of Medicine, Tucson, Arizona Correspondence Address: Kenneth V. Iserson, MD, Section of Emergency Medicine, University of Arizona College of Medicine, Tucson, AZ 85718 e Abstract—Hypnosis can diminish pain and anxiety for many emergency patients during examinations and procedures. While hypnosis has been used for millennia and was demonstrated to be of use in clinical medicine more than a century ago, modern physicians have been reluctant to adopt this technique in clinical practice. This article describes four children with angulated forearm fractures who had no possible access to other forms of analgesia during reduction, and in whom hypnosis was used successfully. A simple method for hypnotic induction is described. © 1999 Elsevier Science Inc. use of hypnosis. Braid first coined the term “hypnotism” in the 19th century, and many well-known physicians, including Charcot and Freud, used the method. Although articles that discuss emergency department (ED) or Emergency Medical Services (EMS) use of hypnosis have sporadically appeared over the past 40 years (1–7), most traditional physicians have been reluctant to use this simple technique in their practices. This may be due to a lack of training, the association of hypnosis with alternative (complementary) medicine, or because of its association with stage shows. The ED where patients in pain or with fear are frequently treated, represents one area in which hypnosis could be an effective tool in the physician’s armamentarium. Among potential symptom-oriented uses of hypnosis in emergency medicine are: 1) to treat possible conversion reactions (for which the amobarbital interview has been described as chemical hypnosis) (8); 2) to treat pain associated with dislocation and fracture reductions (3,9 –11); 3) to treat acute stress reactions, post-traumatic stress disorders, and factitious seizure (12); 4) to relieve the anxiety of needle phobias (1); 5) to treat the pain of burns (13); 6) to treat headaches; 7) to prepare patients for surgery, pelvic or post-rape examinations (14), or labor (15); and 8) to relieve pain and anxiety prior to ED procedures, such as suturing or incisions and drainage (15). This article describes a simple method for the use of hypnosis in the ED setting and the successful use of e Keywords— hypnosis, anesthetic; fractures; emergency medical services; emergency services, hospital; pediatrics INTRODUCTION Hypnosis, a state of wakeful suggestibility, has been used for millennia in medical and religious practices under various names. Egyptian priests, under the name “sacred sleep,” used hypnosis for religious and medical purposes at least 4,000 years ago, while the ancient Greeks were treated with hypnosis in “sleep temples of the sick.” Mesmer, an Austrian physician, first formally described the phenomenon in the 18th century under the rubric “animal magnetism.” In 1831, Elliotson, a professor of medicine at London University, published the booklet, Numerous Cases of Surgical Operations Without Pain in the Mesmeric State. He was later forced to resign from University College Hospital because of his Clinical Communications (Pediatrics) is coordinated by Roger Barkin, MD, of Columbia Health Care, Denver, Colorado RECEIVED: 8 October 1998; FINAL ACCEPTED: 6 May 1998 SUBMISSION RECEIVED: 20 April 1998; 53 54 K. V. Iserson Table 1. CLASSIC METHOD of Characterizing Hypnotic Stages Awake Hypnoidal Light Hypnosis Medium Hypnosis Deep Hypnosis Normal mental state. Physical relaxation, drowsiness but aware, fluttering eyelids, closing eyes, limb heaviness. Partial limb catalepsy, inhibition of small muscle groups, slow and deep breathing, slow pulse. Complete muscle inhibition and stocking/ glove anesthesia. Dilated pupils, complete anesthesia, depressed respiration and pulse, hallucinations. This is the description often used for hypnotic stages in the older literature (21). hypnosis in an emergency department for manipulative reductions of forearm fractures in children. Hypnotic Method Although practitioners use many methods for inducing hypnosis (16), I have found the following method to be extremely easy for physicians and EMS personnel (3). (I was taught a form of this method in medical school and have used and taught this method in ED and in wilderness medicine for more than 20 years.) The process is described to patients as a way to relax, so as not to scare them and to easily explain what is to occur. Misconceptions about hypnosis can have a negative effect on the ability of patients to cooperate fully with the technique. Adults who have undergone hypnosis previously often recognize the process immediately, no matter what it is called, and then often achieve faster and deeper hypnosis. In children, even if the term “hypnosis” is used, it is not clear whether they would understand it. It is essential that the concept of patient and clinician cooperation, frequently described as permissive hypnosis, be explained to the patient. While such feelings are common in adults, children rarely experience unusual feelings of domination, control, or coercion by the clinician (17). During the “preinduction” phase, rapport is established with the patient. (In adults, their prior experiences and the relationship between this technique and their experiences are discussed.) A key element in all cases, especially in the noisy environment of the ED, is to reinforce that the patient should listen only to the clinician, and that the process will proceed at the patient’s pace, without pressure. The clinician speaks in a firm, quiet manner, in no way reacting to any of the noisy or distracting activities in the immediate vicinity. At this point, in a technique refined from Schultz’s texts on autohypnotic training, the patient is instructed to close the eyes and relax (18). Unlike adults, children in stressful conditions are already considered in the first stage of hypnosis (Table 1), and so are generally more susceptible to hypnotic suggestions. The patient is then asked to concentrate on the distal extremities (toes), to imagine sensations of heaviness and pleasant warmth in the limbs as “all of the muscles in the toes relax.” For most people, feelings of heaviness are easier to imagine than warmth, but this is not consistent. The clinician should continue to suggest both sensations. A significant amount of time (30 to 45 s) is spent helping the patient to concentrate on and relax the toes. If this can be accomplished, the remainder of the procedure is much easier. The clinician then suggests that the patient feel the warmth or heaviness flow up into the feet, then the legs, thighs, etc. A significant indication that the technique has been successful is the regularization of the patient’s respiratory pattern. A suggestion to the patient at this time should be to slow the rate of breathing and further allow the entire body to relax. It is optimal to suggest that with each exhalation, another level of relaxation will be attained. The patient is then told that he or she will feel relaxed, sleepy, and will “travel in the mind to a very pleasant place, perhaps a beach or mountain.” A suggestion can be made that the patient will not remember the process of, and pain during, the fracture reduction. Although many tests have been devised to assess the depth of hypnosis, these tests have little clinical relevance (19,20). In a clinical setting, results are what matter, and they do not always correspond to abstract measures of hypnotic success. It is, therefore, unnecessary for clinicians to administer any of these tests. The techniques related to emergence from a hypnotic state may not be needed. The manipulation associated with reducing forearm fractures (or joint dislocations) normally arouses the patients to a prehypnotic state. However, if a posthypnotic suggestion for pain relief or selective amnesia has been given, this still may be in effect (Table 2). Table 2. EXTENDED NORTH CAROLINA SCALE: An OpenEnded Scale Based on Subjects’ Self-Reports, with Numbers Assigned to a Few Specific Events* 0 1–12 20 25 30 40 501 * Reference 26. Normal mental state. Relaxed, detached, ideomotor movements. Analgesia. Dreams. Amnesia, mental quiet, very high suggestibility. All effects completely real. Mind sluggish. Hypnosis for Pediatric Fractures CASE REPORTS After observing two children have forearm fractures set without any form of sedation or anesthesia in the ED of Hospital General, Guanajuato, México, the author suggested trying hypnosis to sedate future children before their forearm fractures were set. The attending orthopedic surgeon was willing to allow the technique in his patients, although he was not convinced it would succeed. His attitude mirrored an old statement in the orthopedic surgery literature, that the use of hypnosis “in orthopedics has been neglected and maybe even derided” (21). That stage hypnosis, both in theaters and on television, is widely known in México may have led to some of his skepticism. Pediatric patients in this hospital generally have no access to general or regional anesthesia for closed forearm fracture reductions because of lack of equipment and personnel. The above orthopedic surgeon, like many in México, feels that hematoma blocks result in an unacceptably high infection rate. Therefore, fractures were routinely reduced without any anesthesia or sedation— especially in children. Over a 5-week period, four children, ages 3–12 years old, two boys and two girls, with forearm fractures presented to the ED while the author was on duty. Two fractures were of the Colles-type and two were midforearm with angulation. The hypnotic inductions were accomplished within 3–5 min and without difficulty in the four children, using standard hypnotic induction techniques (described above). The hypnotic suggestions were continued throughout the 2- to 3-min periods needed for fracture reduction. All of the inductions were done in less-thanfluent Spanish. The initial hypnotic suggestion was to sleep and not to feel pain. The subsequent hypnotic suggestion was for the patients not to remember the pain or process for reducing their fractures. An orthopedic surgeon actively manipulated all these fractures to achieve a successful reduction. As with most uses of clinical hypnosis, it was difficult to determine whether it had been effective until the procedure was completed. All patients appeared awake at the time of the greatest amount of fracture manipulation and seemed to experience pain. However, three of the four patients seemed to go into a peaceful sleep state immediately following the reductions. One of these children even asked if she could go back to sleep immediately after the reduction. Other than the use of hypnosis, all procedures for these patients followed the hospital’s practice standards. After plaster casts were applied, native Spanish speakers questioned the patients approximately 2 h post-reduction about their memory of the procedure and whether they 55 had experienced any pain. When questioned, all of the children seemed confused about what had occurred. They all, even the youngest, clearly said that they had had a fracture and now had a cast, but none of them remembered how the cast was applied or any of the procedures in between. They all denied having any pain during their stay in the ED. Post-reduction films demonstrated adequate reductions for all patients. Despite encouragement, the local physicians were still reluctant to use hypnosis themselves. No informed consent was needed for these cases, given that hypnotic induction was simply a part of the patient’s clinical treatment, and there were no control patients. It was not an option to administer any other type of sedation during a painful procedure, and the process was non-invasive. DISCUSSION Hypnosis remains an enigma. It is a wakeful state without demonstrable changes on electroencephalograms, but it allows the mind to perform feats usually impossible, such as purposeful amnesia for events, relaxation of painful body parts, and the dissipation of acute anxiety. Individuals can hypnotize themselves, and the technique has been used since antiquity by medical practitioners, by performers, in religious ceremonies, and in other settings under a variety of names and guises. The technique itself is easy to learn, and many physicians with a “good beside manner” probably use some of the basic techniques, such as calm reassurance, a steady speech cadence, and a laying on of hands. In the cases presented above, the effectiveness of hypnotic techniques, rather than the hypnotic language was emphasized by the author’s limited knowledge of Spanish. It appeared that the clinician’s attitude, behavior, and steady voice, as much as any basic suggestions, caused the hypnotic state. In the acute setting, the successful use of hypnosis is determined by whether it achieves its immediate goals, which are adequate relaxation for the reduction of a dislocation, diminished anxiety so that an adequate physical examination can be performed (especially in children), or the absence of any memory of pain. According to Erickson, one of the leaders in the field of hypnosis, “In order to make use of hypnosis to deal with pain, one needs to look upon pain in a most analytical fashion. Pain is not a simple, uncomplicated noxious stimulus. It has certain temporal, emotional, psychological, and somatic significance. It is a compelling motivating force in life’s experience. It is a basic reason for seeking medical aid” (22). No one can determine whether a patient is adequately 56 K. V. Iserson hypnotized until after the fact. If there is a drawback to using hypnosis in the ED, it is the fact that studies have shown that even experienced hypnotists cannot determine which patients are actually hypnotized and which are pretending to be in a hypnotic state. However, as with the use of anesthetics, if it doesn’t work, the physician can either try it again or use another technique. Hypnosis is an ideal technique for practitioners in settings with limited equipment or medications, severe time constraints (such as in potentially dangerous battlefield or wilderness situations), or a lack of trained personnel. The easiest way to learn hypnotic induction methods is to watch experienced clinicians. This both instills confidence in the novice and provides nuances not easily gained from texts. However, as with the local physicians in this case, ingrained prejudice against the technique may limit the willingness to use it. Practice and patience are necessary for success. Patients’ susceptibility to hypnosis varies with their age, personality, mental alertness, prior experiences with hypnosis, and the circumstances. Those most susceptible are children between the ages of 7 and 14 years (23). However, achieving hypnosis in a particular patient varies not only with the patient’s susceptibility, but also with the practitioner’s skill and experience and the personal interaction between the hypnotist and patient. Theoretical dangers have been reported for the use of hypnosis in inappropriate circumstances or with repeated self-hypnosis. Most problems arise in the treatment of neuroses and other psychiatric illnesses, or by stage (performing) hypnotists who use the technique for entertainment (24). Since there is no physiological or psychological danger unique to hypnosis, it is unlikely that the circumstances surrounding the use of hypnosis in an acute medical situation would instigate any adverse complication (3,25). The advantages of hypnosis over other methods commonly used in emergency situations are: no additional equipment or medications are needed; no risk of infection; no prolonged sedation; and there are none of the hazards associated with sedation or medication administration. While it is unlikely that fractures will generally be reduced under hypnosis in most U.S. or Canadian EDs, this technique offers significant opportunities for those working outside of these situations, such as in countries or institutions with a relative paucity of equipment and trained personnel, or in out-of-hospital situations, such as in battlefield and wilderness medicine. CONCLUSIONS Hypnosis is a simple, non-invasive tranquilization technique that can be easily and safely used in the ED and EMS system. Hypnosis appears to, at least somewhat, transcend language barriers. Physician attitudes toward and cultural myths about hypnosis may limit some practitioners’ willingness to use the technique. REFERENCES 1. Bierman SF. Hypnosis in the emergency department. Am J Emerg Med 1989;7:238 – 42. 2. Kohen DP. Applications of relaxation/mental imagery (self-hypnosis) in pediatric emergencies. Int J Clin Exp Hypn 1986;34:283– 94. 3. Iserson KV. Relocating dislocations in a wilderness setting: use of hypnosis. J Wild Med 1991;2:22– 6. 4. Paris PM. Pain management in the child. Emerg Med Clin North Am 1987;5:699 –707. 5. Goldie L. Hypnosis in the casualty department. Br Med J 1956;2: 1340 –2. 6. Wain HJ, Amen DG. Emergency room use of hypnosis. Gen Hosp Psych 1986;8:19 –22. 7. Deltito JA. Hypnosis in the treatment of acute pain in the emergency department setting. Postgrad Med J 1984;60:263– 6. 8. Morris DP. Intravenous barbiturates: an aid in the diagnosis and treatment of conversion hysteria and malingering. Milit Surg 1945; 96:509 –13. 9. Vannoni S, Brugnoli A. L’ipnoterapia in ortopedia e traumatologia. Minerva Ortopedica 1971;22:77– 83. 10. Lehe JL. The use of hypnosis in the treatment of musculo-skeletal disorders. Am J Clin Hypnosis 1970;13:131– 4. 11. Hopayian K. A brief technique of hypnoanaesthesia for children in a casualty ward. Anesthesia 1984;39:1139 – 41. 12. Williams DT, Spiegel H, Mostofsky DI. Neurogenic and hysterical seizures in children and adolescents: differential diagnostic and therapeutic considerations. Am J Psychiatry 1978;135:82– 6. 13. Ewin DM. Emergency room hypnosis for the burned patient. Am J Clin Hypn 1986;29:7–12. 14. Valdiserri EV, Byrne JP. Hypnosis as emergency treatment for a teen-age rape victim. Hosp Community Psychiatry 1982;33:767–9. 15. Ambrose G, Newbold G. A handbook of medical hypnosis. London: Baillière Tindall; 1980. 16. Esdaile J. Hypnosis in medicine and surgery. New York: Julian Press; 1957. 17. DeBetz B, Sunnen G. A primer of clinical hypnosis. Littleton, MA: PSG Pub; 1985. 18. Schultz JH. Autogenic training: a psychophysiologic approach in psychotherapy. New York: Grune Stratten; 1932. 19. Cohen SB. Tests of susceptibility/hypnotizability. In: Wester WC, Smith AH, eds. Clinical hypnosis: a multidisciplinary approach. Philadelphia: JB Lippincott; 1983. 20. Radtke HL, Spanos NP. The effect of rating scale descriptors on hypnotic depth reports. J Psychol 1982;111:235– 45. 21. Matles AL. Hypnosis in orthopedics. Am J Orthopedics 1965;7: 101– 4. 22. Rossi EL, ed. The collected papers of Milton H. Erickson on hypnosis: innovative hypnotherapy, vol. IV. New York: Irvington Pub; 1980:238. 23. Rowley DT. Hypnosis and hypnotherapy. Beckenham, Kent, UK: Croom Helm, Ltd.; 1986:40 –59. 24. Crasilneck HB, Hall JA. Clinical hypnosis—principles and applications. Orlando: Grune and Stratten; 1985. 25. Conn JH. Is hypnosis really dangerous? Int J Clin Exp Hypnosis 1971;20:61–76. 26. Rowley DT. Hypnosis and hypnotherapy. Beckenham, Kent, UK: Croom Helm, Ltd.; 1986:29 –30.