Eur J Pediatr DOI 10.1007/s00431-017-3018-5

SHORT COMMUNICATION

Disaster zones—should we be clowning around? Uri Ilan 1 & Avigail Davidov 2 & Joseph Mendlovic 3,4 & Giora Weiser 3

Received: 19 April 2017 / Revised: 13 September 2017 / Accepted: 15 September 2017 # Springer-Verlag GmbH Germany 2017

Abstract Medical clowns have an important role in helping patients cope with their pain and distress. This is especially true in the pediatric population. However, their activity in a disaster area is unheard of. Following the Nepal earthquake in 2015, the Israeli field hospital set up in Kathmandu, Nepal was joined by five volunteer medical clowns. They were active in all parts of the field hospital. Following the hospital’s activity, an online questionnaire was sent to the field hospital members to assess the impact of medical clowning on the hospital in general and its members’ individual performance. Physicians and nurses found that medical clowning had a positive impact both generally and personally. (65.4 and 78.3% respectively on general impact.) Personnel that were not previously exposed to medical clowning also found them to have a positive impact; however, they were less likely to view it as impacting their personal performance.

Communicated by Mario Bianchetti * Giora Weiser [email protected]

Conclusion: Medical teams in disaster areas may benefit from the presence of medical clowns. What is known about this topic: • Medical clowns are used for alleviation and distraction in painful and distressful medical procedures and treatments. Its positive effect on patients, and their families are well established. What this study adds: • This is the first description of medical clowning in a disaster area. In addition, the impact of medical clowning on the medical staff working in a disaster area is evaluated. No previous studies have explored the impact of medical clowns on the medical staff.

Keywords Disaster . Medical clown . Pain . Children

Abbreviations FMT Field medicine team IFH Israel field hospital MC Medical clowns

Uri Ilan [email protected]

Introduction

Avigail Davidov [email protected]

On April 25, 2015, a 7.9 grade Richter scale earthquake struck Nepal. Cities and villages were devastated with over 8000 victims and countless of people injured. Many countries offered and sent medical aid. One of the largest teams to arrive was the Israeli field hospital (IFH) which offered the highest level of field medicine team (FMT level 3), defined as a Bstand alone^ medical facility [7]. The IFH treated an excess of 1600 patients in 12 days of activity with a third of the patients being pediatric. The IFH team consisted of physicians, nurses, paramedics, and other medical personnel (laboratory, pharmacy, radiology, and others). The IFH totaled 122 members. During

Joseph Mendlovic [email protected] 1

Pediatric Hematology-Oncology, Hadassah Ein Kerem, Jerusalem, Israel

2

Hebrew University- Hadassah Medical School, Jerusalem, Israel

3

Pediatric Emergency Medicine, Shaare Zedek Medical Center, 12 Baith St, Jerusalem, Israel

4

Ministry of Health, Jerusalem, Israel

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the IFH activity, five medical clown (MC) volunteers arrived from Israel to participate in the hospital’s activity. They were integrated in all of the IFH’s departments, working with both adult and pediatric patients. The use of MC for alleviating pain and distress has been in practice for close to 30 years in hospitals throughout the world [3]. There is evidence showing the effect of medical clowning on the well-being of patients, especially regarding painful and distressful procedures [4–6]. The effect of clowning lies on the assumption of the relationships between brain and endocrine immunological and physiological aspects. The emotional impact of laughing creates a special bond between the patient and the clown and may cause distraction from the extreme conditions of the disaster, bereavement, and chaos. The well-being of patients is based not only on biased perception but likely on immune modulation of inflammation [1]. These effects have been reported in adult patients as well as pediatric [2]. Although MC receive formal recognized training on the approach to patients in a state of trauma (physical and emotional), the approach to such patients in a disaster zone is undescribed. We sought to try and understand the impact of MC presence on the IFH medical crew during deployment. Limited manpower, equipment, and budgeting have an impact on the conditions within which the field hospital operates. Working in a disaster zone poses difficulties for the medical staff on a professional and emotional level. MC as part of such a delegation may be viewed negatively at it uses resources and budgets that come at the expense of possible life saving activity. As the MC that joined were volunteers, this was an important opportunity to assess how the team views their contribution to the hospitals activity.

Methods An online survey assembled by the authors (UI, SM, and GW) was sent to all available members of the IFH. The short questionnaire was a Likert scoring questionnaire focusing on the perceived impact by each IFH member on the IFH in general and on their personal performance. The results were analyzed using the Fisher’s exact test, IBM SPSS statistics software (2015). The questionnaire was Likert-based and answers ranged from 1 being very negative to 5 being very positive. The results were aggregated to three basic groups—negative impact (scores 1 and 2), no impact (score of 3), and positive impact (scores 4 and 5). The study was approved by the Israel defense forces ethics committee.

Results The questionnaire was answered by 58 members of the direct medical team. The other members (medical, radiology, and

laboratory technicians) offered sporadic answers and therefore were not included. The questionnaire showed a high internal consistency and was thus considered relatively reliable for the groups presented. 79.6% of the IFH members were exposed to the MC activity frequently or on a daily basis. 82.6% agreed that the MC helped to bridge language barriers with patients. None of the medical staff reported any cases of coulrophobia. 1) Physicians—26 physicians of varying medical professions were available. These included emergency medicine, surgeons, orthopedists, pediatricians, internists, otolaryngologists, ophthalmologists, and gynecologists. Of these physicians, 17 (65.4%) had previously been exposed to MC. Regarding the impact of MC on the IFH staff in general, 50% noted a very positive impact. The total positive impact assessed was 65.4% on the IFH staff. 30.8% noted no impact. Regarding the impact of MC on their personal performance, 42.3% found that there was a positive impact, and 11.5% noted a very positive impact. 2) Nurses—23 nurses from different specialties were part of the IFH team. 56.5% of the nurses had previous exposure to MC. 78.3% of nurses found that MC had at a positive impact on the IFH. Only one nurse noted a negative impact. Regarding personal performance, 52.2% answered that MC had a positive impact, and 21.7 found that the MC did not impact their performance. Interestingly, 6 nurses (26.1%) noted a negative impact on their personal performance. 3) Paramedics—The nine paramedics on the IFH team are not employed in hospitals in general in Israel. There was a lower exposure of any sort to MC (33.3%). The paramedics found MC to have a positive impact in 44.4%. No impact in 44.4% and one paramedic stated that MC had a negative impact on the IFH. As to their personal performance, only 22.2% felt that MC had a positive impact, while 55.6% felt no impact, and two paramedics stated a negative impact (Table 1).

Table 1

Results of the questionnaire based on role in the IFH

Staff member (N)

Positive impact (%)

No impact (%)

Negative impact (%)

Physicians (26) general impact Physicians personal impact Nurses (23) general impact Nurses personal impact Paramedics (9) general impact Paramedics personal impact

65.4 53.8 78.3 52.2 44.4 22.2

30.8 46.2 17.4 21.7 44.4 55.6

3.8 – 4.3 26.1 11.2 22.2

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Discussion

Conclusion

Medical clowning as a form of pain and distress alleviation has become an important part of patient care in many medical centers, especially in pediatric medical centers [8, 9]. The impact of MC goes way beyond a simple smile or laugh. The emotional and physiological effects can add a great deal to the ability of all those involved to manage with difficult situations. A disaster area by definition holds in its midst a deep sense of tragedy that affects both the population involved and injured as well as the teams coming to assist. At times of disaster, the focus should be on saving as many lives as possible and rebuilding basic life infrastructure in the area. However, addressing the distress and suffering should be a basic humanistic part of the help offered. The presence of MC in a disaster area has not been previously described. To our knowledge, no relief group or field hospital team employs MC. The MC that joined the IFH were volunteers and are part of an Israeli medical clown group (www.dreamdoctors.org.il). Disaster areas suffer from extreme disparity. Using resources for recruiting MC is a luxury not to be considered generally. However, when available, their impact may go further than just the local population involved. The findings of this basic questionnaire show that the MC had more than just the expected impact on patients and their families. The IFH staff who worked under harsh conditions was by the most part positively affected. This finding was expressed by all parts of the IFH. Only a small proportion of the medical staff felt that the MC had a negative impact on the IFH activity. As the questionnaire was anonymous, there is no way to explore the exact explanation of these impressions. We found that nurses are more likely to find the MC activity negative. This may stem from interfering with activity in the busy departments and would indeed mostly impact the nursing activities. The less a staff member was previously exposed to MC, the less likelihood they will find a positive impact on the IFH in general and their performance personally. The acknowledgement of the MC impact at a previous work place most probably leads to a positive impression of their activity in a disaster situation. These results although assembled from a small number of participants who answered the questionnaire and the questionnaire not being more detailed and with open-ended questions may encourage examining the addition of MC at least in areas where many children are affected. The main goals of disaster medicine must remain focused on the saving of as many lives as possible. However, considering the addition of MC if possible will probably have a positive impact on all those involved. Relief teams arriving at such areas may consider adding MC with proper training or inviting volunteer MC to join their activity.

The activity of MC in a disaster area was viewed as a positive addition to a field hospital by most medical personnel in the IFH. Although MC as part of a relief team seems an unusual addition and at times unnecessary, their value can be important for all those involved, and their participation should be encouraged. Acknowledgements We wish to thank the entire IFH team for their tireless effort to help all those in need, the Nepali people for their courage and kind hospitality, and the medical clowns who volunteered to join such a noble cause. Authors’ contributions UI- designed the study and the questionnaire and help drafting the manuscript. SM- designed the online questionnaire and helped drafting the final manuscript. AD- analyzed the collected data and critically reviewed the manuscript. GW- designed the study and the questionnaire. Drafted the manuscript through its final draft. All of the authors critically reviewed the manuscript and took responsibility for the final draft. Compliance with ethical standards Conflict of interest The authors declare that they have no conflicts of interest. Studies with human participants or animals This article does not contain any studies with human participants or animals performed by any of the authors.

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