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The Journal of Emergency Medicine, Vol. 17, No. 1, pp. 53–56, 1999
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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
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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
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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.
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