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BOPAS - Burn Observational Pain & Anxiety Scale

Dr. Rene Albertyn’s groundbreaking invention -The Burn Observational Pain Anxiety Scale (BOPAS) - has captured world attention. As, South Africa’s only doctor specialising in pain control Rene accidentally found herself catapulted onto the world’s medical limelight several years ago. 

It began as a nightmare on her first day of work as medical social worker for Cape Towns’ Red Cross War Memorial Children’s Hospital.

Rene shrugs,  “I certainly wouldn’t have done this myself….” Head of Paediatrics, Professor Rode walked up to me when I hardly knew y way round the hospital and said, “Find out why the children are crying.  I don’t know how to adequately manage burn victims pain in the outpatients department.  The nurses complain that the children scream.  Go down and assess the problem.”

“I walked into hell.  It was taking a trip into Dante’s inferno.” She gesticulates wildly with outstretched palms.  “There was a mass of 28 screaming pain riddled distressed children, their heartbroken parents and helpless nurses.  I couldn’t translate what I saw. I couldn’t describe my feelings in words.  This was enormous. Bigger than imaginable, beyond shocking, worse than any nightmare. “Before I had just used kiddies drawings to assess their pain. 

“Totally inadequate.” 

“I saw screaming children held down by adults to have their dressings changed.

 Later, I saw children vomit from pain or jump off the bed from sheer agony.  The physical and mental traumatic effect of burn victims pain, if not handled correctly, is everlasting.” 

“I was thrown in at the deep end.  Professors’ Heinz Rode and Syd Cywes, two heads of Paediatric Surgery presented me with challenges previously unimaginable.” 

Rene shrugs, “I was so far out of my depth that I resorted to taking a video   capturing14 minutes of the children’s pain on film.  I called the doctors and students downstairs, stretched my hands in the air and said, “I have a problem.  What is this? Tell me what I am looking at?” 

“In the audience was a very special person, Dr. Jenny Thomas, Senior Specialist Paediatric Anaesthetist, who joined the hospital at the same time as me. Jenny jumped up suddenly and shouted, “This will stop. Now. Today.  “This type of thing can’t happen where I work.”  

“Within 24 hours Jenny had written a paper on pain protocol.  From this, the idea of measuring each child’s pain tolerance individually was born.  I spent every waking moment, and had too many nightmares conjuring a way to measure pain.  I found the problem particularly complex because I had no examples to go by.  There was nothing like it anywhere in the world.  South Africa is unique in many ways. We can’t learn from first world countries where they have sophisticated techniques.   Our rainbow nation has children with different cognitive developmental levels, diversity of cultures and language barriers. 

“Finally, I could absorb the data and transform it into a concept anybody can understand, regardless of language or background.”  

From then onwards, pain control has been ongoing research that Rene works at obsessively.  Nowadays, she can measure the pain a babe infected with AIDS goes through while being born. 

Rene smiles proudly, “Unfortunately, I have the entire Red Cross (330 children) to look after – with one professional nurse and Jenny Thomas. I don’t only work on pain assessment in the burn unit – but for the entire hospital.” 

So how exactly would one describe BOPAS (Burn Observational Pain and Anxiety Scale) and its workings? 

The BOPAS Scale is a unique concept whereby each child’s pain level is personally assessed so they can be administered a complex cocktail medication, thereby alleviating emotional and physical pain.  

BOPAS (Burn Observational Pain and Anxiety Scale) is an observational scale that differentiates between pain and anxiety during burn and wound care procedures including dressing and bandaging.

It consists of six categories:

  • crying
  • verbal ability
  • facial expression
  • torso-movement
  • leg movement
  • and touch.”

Get Rene on this subject and she flows freely for hours. “This is the only scale in the world that can measure both pain and anxiety independently in a child during a procedure. 

“The numerical value of scoring determines the percentage of pain or anxiety the child experiences during a procedure.  You will know whether the child was adequately medicated for both pain and anxiety, or whether the little patient was over-sedated.  You will know if a change in the drugs or dosage should be recommended.” 

“Remember,” she says waving her index finger, “we use different drugs for pain and anxiety, so they are independently medicated.  I must know if the separate management of both pain and anxiety are okay.”  

“It is purely observational and excludes all communication. Hell, we have 11 languages in South Africa, differing cultures ….etc,” she trails. 

“Language barriers alone prevented paediatric pain management in the past. So simply nothing was done.” 

Rene’s regime in the burn unit is as follows: 

  • First she assesses the severity of the wound to find how deep the burn is; the percentage of body surface involved, and the area and severity. In other words the wound in its entirety is assessed. 
  • Thereafter Rene determines the combination and cocktail of drugs and sets protocols for treating the wound. 
  • During the procedure the pain and anxiety is measured using BOPAS scale measurements to determine if the drugs provided adequate relief and if necessary change or add drugs for the next procedure, which takes place the following morning. 
  • Later Rene always, where possible speaks to the mother – and this, she emphasises is the most vital part of pain management. 

“Nobody knows the child better than the mother Here you find out about the child’s previous pain experiences, words that might be used to indicate pain, what the child does when in pain as well as maybe previous medical history and pre-morbid personality. Basically, we need to know how the child reacts when in pain.” 

It is important to conduct the assessment for at least three days thus ensuring the drug combination and doses are consistently correct, as each child should be treated as an individual and have their own individual pain plan.  The efficacy of the plan must be reassessed daily. 

Rene’s creativity doesn’t end with BOPAS.  She has only just developed a set of ‘Comfort Scales’ for children that can measure comfort versus discomfit.  This is physical – pain, and emotional discomfit such as anxiety, fear, stress, loneliness in very small children. 

For Rene – as well as every parent – this is very exciting and a new way of dealing with sick kiddies pain or anxieties. And, yes, again, this too is very different to what is done throughout the rest of the world.  

 “We have the first – and at the moment only – paediatric pain management department in South Africa,” emphasises Rene. 

Unfortunately, South Africa also leads the field with the highest rate of burn victims in the world per capita, with the Red Cross alone, treating a minimum of 1 000 victims each year.  

At a time when the Hippocratic Oath of healing often means less than the paper it’s written on; when medical treatment is measured in terms of money; when one is assailed daily by media headlines highlighting the deplorable state of medical care in hospitals; when it’s often less troublesome and more dignified to die quietly at home than sign your own death certificate seeking treatment at a State Hospital; when South African’s are ashamed of the state of State Hospital’s-and when the doctors and nurses leave South Africa for better pay and brighter shores, Rene Albertyn is only one of an inspirational and groundbreaking medical team. 

“At the Red Cross, War Memorial’s Children Hospital we all find it just wonderful to see kiddies become whole again,” laughs Rene.

Written by Lana Jacobson for TLC Magazine


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