Elba Rahmouni & Olivier Guillard

Since April 2018, Elba has been in charge of dissemination at CRASH. Elba holds a Master's degree in History of Classical Philosophy and a Master's degree in editorial consulting and digital knowledge management. During her studies, she worked on moral philosophy issues and was particularly interested in the practical necessity and the moral, legal and political prohibition of lying in Kant's philosophy.
Paediatrician at the Paris Urgent Medical Aid Service (Service d’aide médicale urgente – SAMU in French) since June 2020. Olivier Guillard also holds a Master’s in political science, development and humanitarian aid. During his professional practice, he worked in teaching positions in paediatric cardiology and cardiac resuscitation units (hôpital Necker – Enfants malades and hôpital Marie Lannelongue), at Doctors Without Borders, and as project manager at the Samusocial de Paris. He develops technical assistance projects at the Paris SAMU in partnership with the department of international relations at AP-HP (Paris public hospitals authority), the City of Paris and the Samusocial de Paris. In addition, he supports the inclusion of social sciences in research on prehospital emergency care.
Based on the example of the hospital in Moïssala, Chad, the two authors reflect on the management of pain in children at Médecins Sans Frontières. This article was first published on March 25th 2022 in the journal Alternatives Humanitaires.
Although acute pain has a diagnostic value and can play a positive role as a warning sign to promote the body’s own survival, there is no question that it is necessary to treat and prevent it, particularly in the context of care. It is both a medical necessity, to avoid complications, and an ethical necessity, based on the principles of benevolence and primum non nocere (“First, do no harm”)Conseil national de l’Ordre national des médecins, Code de déontologie médicale, février 2021, https://www.conseil-national.medecin.fr/sites/default/files/codedeont.pdf. It is also a social necessity: injuries can lead to chronic pain which can then lead to disabilities« Loi n° 2005-102 du 11 février 2005 pour l’égalité des droits et des chances, la participation et la citoyenneté des personnes handicapées », Journal officiel de la République française, 12 février 2005, https://www.legifrance.gouv.fr/jorf/id/JORFTEXT000000809647
Compared to adults, pain in children was only taken into account relatively late, towards the end of the twentieth century. Children, and especially newborns, were considered to be neurologically immature and therefore insensitive. The difficulty they had in expressing their pain and the non-recognition of their inability to play their social role of learning and playing in the event of pain (or disability) also contributed to this delay. The pain management of the suffering child became commonplace in the English-speaking world and then in France from the 2000s.
In order to explore the contemporary issues surrounding the suffering child in the humanitarian field, we began by observing the non-management of pain in a hospital in Moïssala in ChadThe country is ranked 187th out of 189 countries in the 2019 Human Development Index ranking developed by the United Nations Development Programme. It is included in the list of least developed countries established by the Organisation for Economic Co-operation and Development’s Development Assistance Committee and the list of highly indebted poor countries published by the International Monetary Fund.
Given that children (and especially children under 5) are a priority target in the humanitarian field, how can we explain the relative non-management of pain of the suffering child in the practices of and concerns faced by the Moïssala hospital where MSF works?
Pain and its paediatric particularities
The International Association for the Study of Pain (IASP) defines pain as an unpleasant sensory and emotional experience associated with actual or potential physical injury. Pain is always subjectiveInternational Association for the Study of Pain, “IASP announces revised definition of pain”, 16 July 2020, https://www.iasp-pain.org/publications/iasp-news/iasp-announces-revised-definition-of-pain
This integrated pain system was only partially understood in the 1980s. The idea that newborns could feel pain was therefore disputed. Two events contributed to the evolution of society and medicine. In 1986, following the intraoperative death of her newborn child, a mother discovered the absence of analgesia during surgery in the medical records. She then published a series of articles in the pressS. and Y. Rovner, “Surgery without anesthesia: can preemies feel pain?”, The Washington Post, 13 August 1986, https://www.washingtonpost.com/archive/lifestyle/wellness/1986/08/13/surgery-without-anesthesia-can-preemies-feel-pain/54d32183-8eed-49a8-9066-9dc7cf0afa82
In the 1960s, a distinction was made between “caring” and “curing”Chantal Cara et Louise O’Reilly, « S’approprier la théorie du Human Caring de Jean Watson par la pratique réflexive lors d’une situation clinique », Recherche en soins infirmiers, vol. 4, n° 95, 2008, p. 37-45.
Difficulties in pain management, both at individual and institutional levels
In 2020, when the issue of the non-management of pain of the suffering child was discussed with the team at Moïssala, the team answered “that’s how it is here”. And yet the subject of pain management for patients has existed for many years at MSF. Given that the issue is under consideration at headquarters, by heads of anaesthesia and paediatrics departments and by hospital managers, how can we explain the discrepancy between the medical and operational intentions regarding pain management and the practices in certain fields?
In order to explain the individual behaviour of the non-management of pain, we found it possible to determine four ideal types of resistance, which are often interrelated. They concern both caregivers and children or their parents: the caregiver does not manage the pain and the patient (or their family) does not express it.
The negationist denies the existence of pain in the child. This historical figure is the product of a series of beliefs, some of which are supported by erroneous scientific arguments. Cultural biases may lead to some groups of people being considered as being less sensitive to pain.
The dolorist knows that the child is in pain, but their utilitarian vision of this pain prevents them from managing it. They are part of a doctrine inspired by Catholicism and Stoicism which ascribes a high moral, aesthetic and intellectual value to pain. Some doctors still mistakenly believe that pain is a useful clinical sign for monitoring illnesses.
The fatalist knows that the child is in pain, but there is no link between the acknowledgement of pain and the necessity or possibility of relieving it. There is no better illustration of this Catholic heritage than the character of Father Paneloux in Albert Camus’ The Plague. This fatalism can also be explained by a feeling of powerlessness, a kind of institutionalised burn-outDidier Cohen-Salmont et al., Le jeune enfant, ses professionnels et la douleur, Éditions Érès, 2007.
Finally, the abuser knows that the child is in pain but intends to take advantage of this dependency. The resulting sense of power brings the abuser the personal and professional satisfaction that they may be lacking from patients or institutions. This behaviour can lead to corruption: the caregiver can monetise the delivery of care or divert equipment and medicines for commercial endsYannick Jaffré et Jean-Pierre Olivier de Sardan, Une médecine inhospitalière : les difficiles relations entre soignants et soignés dans cinq capitales d’Afrique de l’Ouest, Éditions Karthala, 2003.
In current MSF projects, adult pain is better managed than that of children because of the work largely carried out by the anaesthesia department. Since 2008, the IASP in association with the World Health Organization has promoted the ChildKind initiative with the aim of reducing pain in children worldwide. It is an international accreditation which fosters a standardised approach to the management of the suffering child based on five principles: pain assessment, training, protocols, internal audits and written policyNeil L. Schechter et al., “ChildKind: A global initiative to reduce pain in children”, Pediatric Pain Letter, Special Interest Group on Pain in Childhood, vol. 12, no. 3, December 2010, http://ppl.childpain.org/issues/v12n3_2010/v12n3_schechter.pdf
Pain assessment
If pain was never assessed in Moïssala, there was nothing in the medical records to encourage it. MSF paediatric clinical guides explain the use of certain scales, but there is resistance to their use, often related to the caregiver’s feeling of incompetence: some are paralysed by the range of choice; others are not familiar with how the scales work, which requires learning time. Because of these doubts, the caregiver anticipates the tool’s low reliability by simple transfer of incompetenceDidier Cohen-Salmont et al., Le jeune enfant, ses professionnels…, op. cit.
Training
It is the policy of the organisation not to question the skills of its medical expatriates; there is therefore no training about the management of pain in adults or children before they head off for their mission. To compensate for this gap, the anaesthesia department decided to make the departure of expatriates for which it is responsible contingent on the signing of documents about pain management, similar to opposable medical references. However, by definition, these expatriates are only present on surgical projects, and other departments, including paediatrics, have not appropriated this tool. Although training for doctors in America and Europe now includes pain management, this is not always the case for national medical staff. The need for surveillance and the undeclared feeling of incompetence in the management of complications are major obstacles. However, in Western countries, experience has shown that the protocolisation of various analgesics and sedatives by trained professionals ensures their safe use. For surgical projects, one solution for MSF was to train local anaesthetists, who now do most of the work.
Many caregivers are unaware of non-pharmacological adjuvant treatments, which are often safer and less expensive. The scientifically established effectiveness of psychological and physical pain treatments can be explained by the modulation of the perception of pain by emotions and other cognitive experiencesLeora Kuttner, L’enfant et sa douleur : Identifier, comprendre…, op. cit.
The fear of opiate addiction can be raised by families, institutions (ministries) but also health professionals. This debate is no longer necessary: it has been recognised that their proper use does not cause addiction. The latter is the result of abusive behaviour on the part of both prescribing doctors and at-risk patients.
Protocols
As we have seen above, the safe use of analgesics is promoted by the use of written protocols. These exist at MSF but are published in disparate guides making them difficult to apply, especially at the patient’s bedside.
Internal audits
In the 2000s, an internal evaluation process was put in place for surgical projects, with good results. This is a simple and inexpensive procedure that is an end-of-chain indicator: if the criteria are good, it means that the whole anaesthetic chain works. But its durability requires constant pressure to obtain data from the field. To our knowledge, no such evaluation exists for paediatric projects, at least not in Moïssala.
When these self-assessments were put in place, the institution was somewhat reluctant to transfer Western tools to the field. However, in the 2000s, the mortality rate following anaesthesia in surgical projects by MSF was comparable to that in France in the 1980s with the same causes. It was precisely by implementing all the international structural reforms used in France since the 1980s that the mortality rate following anaesthesia has been reduced tenfold in twenty years.
Written policy
In our opinion, the absence of written policy at the institutional level is one of the reasons for the underuse of existing tools in paediatrics compared to surgical projects. In French healthcare establishments, it was the Kouchner Act of 2002 that was the impetus for change. This political force is probably underestimated at MSF.
Reasons for a slow evolution
In the 1980s, the ambition emerged to manage pain in surgical projects. In order to use morphine, MSF had to contend with the legal difficulties of its delivery and storage. Thanks to the work of Jacques Pinel, a pharmacist and the inventor of humanitarian logistics, the cost of pain treatments has decreased, and their logistical management has been simplified. In the 2000s, the question re-emerged, because although everybody at headquarters agreed to consider pain management as a necessity, there was a complicated transition from theory to practice. Prior to any change, it was necessary to make the institutional failure in pain management visible. The data showed that MSF had performed 12,000 surgical procedures in 2000, for which 25,000 ampoules of Ampicillin (an antibiotic) and only ten ampoules of morphine were sent from Bordeaux. Xavier Lassalle, the pain consultant for the surgical projects at the time, remembers that this data ignited strong reactions: “It was a real blow, impossible to deny, we had to do something.” Yet other voices were raised to recall the medical and operational priorities: “Malaria is more important. A million people have died. There is an emergency. Pain must be treated, but in contexts as appalling and specific as MSF fields, you can’t transpose it so easilyInterview carried out in Paris on 10 December 2020 with Xavier Lassalle, an anaesthetist nurse, a former anaesthesia consultant and a member of MSF’s board of directors until 2021.
MSF is currently advocating for a patient-centred approach, and the tools necessary for effective pain management are now available. Although much has been accomplished in the field of surgery, the management of the suffering child in paediatrics, and particularly in the Moïssala project, remains to be strengthened. What does the lack of pain management mean when it comes to the perception of childhood in the humanitarian field? How can the work of the different departments of the organisation be linked up in order to improve the cross-cutting management of the suffering child? In surgical projects, the local anaesthesiologists trained by MSF have proven to be good ambassadors, but the responsibility of managing the suffering child falls to both institutions and caregivers. We acknowledge the political complexity of this subject, which is reflected by the lack of discussion. We are tempted to question the political under-representation of children in this regard.
To cite this content :
Elba Rahmouni, Olivier Guillard, Management of the suffering child: a medical and operational challenge,
27 April 2022,
URL : https://msf-crash.org/en/publications/humanitarian-actors-and-practices/management-suffering-child-medical-and-operational
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