PRINCESS MARGARET HOSPITAL FOR CHILDREN
Draft 7 by G Beck EXTERIOR. PRINCESS MARGARET HOSPITAL General shots around the hospital. VOICE OVER Princess Margaret Hospital is a large general teaching children's hospital with around 300 beds and is also the only tertiary hospital in the western half of the country. It handles over one third of all child admissions in Western Australia and treats virtually all congenital abnormalities and conditions requiring specialised unit care. INT. SLIDES Slides illustrate the various cases of cleft lip and palate babies. VOICE OVER Cleft palate and cleft lip and palate are a complex problem affecting aesthetics speech occlusion and hearing. They require coordinated multidisciplinary treatment spread over a period of up to 18 years. INT. MONTAGE Various shots of people working in the cleft unit. VOICE OVER The cleft lip and palate unit was established in 1964 by Dr. Harold McComb .... Cut to photograph of Dr. McComb. VOICE OVER (CONT'D) ....the senior plastic surgeon in the hospital, whose objective was for a team approach in the treatment of cleft lip and palate cases. Cut to Photograph of Dr. Brogan. VOICE OVER (CONT'D) Dr W.F.Brogan from the dental department was then appointed to develop an integrated unit combining the four essential teams of plastic surgery, E.N.T., dentistry and speech therapy. Cut to graphics to illustrate the following departments; ----------------------------------------------------------------------------------------------------- 2. PLASTIC SURGERY - E.N.T. - DENTISTRY - SPEECH THERAPY VOICE OVER (CONT'D) This 'team' approach has resulted in the unit being Australia's leading Hospital in the treatment of the congenital physical deformities associated with cleft lip and palate children. Music up. TITLE: THE PRINCESS MARGARET HOSPITAL FOR CHILDREN TEAM APPROACH TO CLEFT LIP AND PALATE TREATMENT. INT. MONTAGE General shots of the cleft unit. VOICE OVER The unit is based on the dental department for several reasons. Good oral health is essential for the successful rehabilitation of a cleft child. To achieve this the child is seen at 6 monthly intervals over the whole treatment period, which may extend over 20 years. The Dental department also provides the base for taking and storing the long term records which are 'essential' if the team is to evaluate and improve its results. INT. ROOM Dr Brogan talks to camera. DR. BROGAN It took about 8 years to develop the dental unit to a stage were it could provide all necessary dental services "in house." During this time treatment protocols were developed, visiting consultants were appointed in all the dental specialities and facilities were expanded to 5 surgeries, laboratory and the research room, which is the centre for record collection. ----------------------------------------------------------------------------------------------------- 3. INT. GENERAL SHOTS VOICE OVER The objective of the unit is to get the primary operation right, giving the child a face, speech and hearing to lead a normal life from 12 months onwards. This approach also significantly reduced the number of secondary operations required. It is based on presurgical orthopaedic treatment commencing at birth, realigning the facial skeleton in the first 2 months of life, allowing the surgeon to restore the soft tissues on a normal foundation. The success of this method led to Dr Harold McComb introducing primary rhinoplasty which was a key element in giving the patient a good facial appearance in the first year of life. [slide James Wood.] This is our main aim, to give the child a face, speech and hearing he can comfortably take to kindergarten. INT. SPEECH PATHOLOGY CLINIC General shots of the clinic. VOICE OVER The ENT and speech therapy services are also brought in at an early stage, seeing cleft patients routinely from 6 months of age, testing hearing and advising on speech development. INT. CLINIC ONE General shots of the clinic. VOICE OVER Linking everything together are the monthly clinics at which all 4 specialties are represented. In the course of a year all patients currently under treatment would be seen, treatment results to date assessed and future treatment planned. These clinics proved to be invaluable in keeping everyone working together and focused on improving results. INT. ROOM Continue Dr. Brogan to camera. ----------------------------------------------------------------------------------------------------- 4. DR. BROGAN The final important aspect of the team approach is dealing with the shock, grief and possibly guilt parents feel with a child having such a visible deformity. There is no easy answer to this, as parents and children can vary enormously in their reaction. We endeavour to ensure that everyone involved in the case, from neonatal paediatricians and nursesonwards are aware of the problem and present a consistent story of sympathy and reassurance, emphasising that this is a physical deformity that can be well treated and the child will lead a normal life. INT. FLYING DOCTOR - DAY General shots of the flying doctor. VOICE OVER The protocol for cleft repair is that where possible all clefts born in the State are immediately transferred to Princess Margaret Hospital Neonatal Unit. With the hospital servicing around one third of Australia the flying doctor service is essential in transferring these patients quickly to the Hospital. INT. NEONATAL UNIT - DAY John Winters is examining a new baby in the neonatal unit. VOICE OVER Here they are evaluated by the paedodontist and plastic surgeon and presurgical orthopaedic treatment is commenced if the case requires it. Most unilateral and bilateral cases and a few very wide cleft palate cases are selected for treatment. INT. MICHAEL'S NURSERY - NIGHT Mrs Beck feeds a 2 month old Michael. VOICE OVER It is essential to comfort and inform the parents at the initial consultation but they are usually shocked and disturbed and take in (MORE) ----------------------------------------------------------------------------------------------------- 5. VOICE OVER (CONT'D) little at this stage. Mothers are encouraged to breast feed if possible, and the Cleft Palate Parents group are a great help in the early stages and some of the older patients are now acting as councilors. [Slides; Danielle Parker] Mrs Beck undoes Michael's strapping. VOICE OVER (CONT'D) The treatment is based on the McNeil Burston passive approach technique, using an acrylic appliance as a mould to encourage growth in defective areas. She takes his plate out. VOICE OVER (CONT'D) An external strapping device is also used to restrain unwanted growth. This treatment commences as soon as possible after birth, and we are normally able to have the segments in position ready for the first operation after 6 weeks. She inserts Michael's plate and strapping. VOICE OVER (CONT'D) In unilateral clefts we aim to have a 4mm gap between the segments to allow access for the initial stages of lip and anterior palate repair and this gap is then closed by a Muir Flap which stabilises the segments. INT. CLINIC ONE A clinic is in session with various patients attending. VOICE OVER Patients attend these combined clinics which are instituted on a monthly basis and are attended by the visiting plastic surgeons, plastic surgery registrar, orthodontist, Paedodontist and speech pathologist. In the background, Dr Winters instructs several students. ----------------------------------------------------------------------------------------------------- 6. VOICE OVER (CONT'D) Undergraduate and post graduate students also attend these clinics as they are a valuable teaching tool. The Dental Unit provides all the clinical undergraduate dental teaching in paedodontics and also provides facilities for post graduate teaching in the paedodontic area for the various masters degrees in the dental specialties. Mrs Beck and 2 month old cleft lip baby Michael interact with doctors and dentist's. VOICE OVER (CONT'D) These clinics also provide an invaluable two way means of communication between the patients, their parents and the surgical and dental staff who are treating them. Cut to live sound. MR BAKER Do you have any concerns? MRS BECK Will the nose be built up at the first operation? MR BAKER We do quite a lot of treatment on the nose at the time of the lip repair. The first operation makes a dramatic change to the baby. INT. PHOTOGRAPHS Case histories show patient's progression. VOICE OVER The unit is able to follow all the cases up from year to year and access changes in treatment and to learn from the progress that is made along the way. Long term follow up is essential in evaluating the results of treatment. Cut to various shots of x-rays, photographs, CT & MRI scans. VOICE OVER (CONT'D) Not only being able to make good consistent long term records, take photographs, x-rays, dental models (MORE) ----------------------------------------------------------------------------------------------------- 7. VOICE OVER (CONT'D) and scans, but being able to store and retrieve them is one of the essential parts of running a cleft unit. INT. WILMA'S OFFICE - DAY Wilma is on the telephone and working on her computer. VOICE OVER Another factor is having a Cleft coordinator who is responsible for the management of the multiple specialties involved. The coordinator also acts as an informational resource for patients and their families. Currently there are 450 cleft palate cases under review with approximately 50 new cases added yearly. A recent study indicated that the unit had a 95% compliance rate confirming the hospitals good long term relationship with their patients. WILMA We have your operation booked for 2 o'clock Mrs Unsworth, could you bring Michael in about 10 in the morning? INT. OPERATING THEATRE A cleft palate operation is being performed by Dr. Baker. Sub title Dr. Baker with current title. (resident plastic surgeon?) TONY BAKER (V.O.) At the initial operation at around three months, the lip, alverous and hard palate is repaired and any deformity to the nose is corrected. This approach has significantly reduced the number of secondary operations required. It based on presurgical orthopaedic treatment commencing at birth that re-aligns the facial skeleton in the first 3 months of life. This allows us to restore the soft tissues on a normal foundation. [We do a Randall/Tennyson or Millard/McComb alar cartilage lift; vomerine flap to hard palate and Muir flap to alveolus. (MORE) ----------------------------------------------------------------------------------------------------- 8. TONY BAKER (V.O.) (CONT'D) Simultaneous bilateral cleft lip repair with vermilion flaps from lateral segments to reconstruct central tubercle. Wing incision to facilitate relocation of alar cartilages and lengthen columella. No muir flaps as all mucosa needed for lip repair. Muscle approximation in midline.] At 6 to 8 months a second operation repairs the soft palate which is important for speech. [It is a two layered repair, nasal and oral mucosa. Mucoperiosteal flaps raised and soft palate muscles dissected under operating microscope magnification. Midline closure of all layers on soft palate] At about 11 or 12 years a third operation bone grafts the gum area to allow normal dentition. INT. SPEECH PATHOLOGIST'S OFFICE The speech pathologist consults with Mrs Beck and 6 month old Michael. VOICE OVER The anatomical anomaly of cleft palate can affect speech development even after its repair and it is for this reason that the speech pathologist is an integral part of the team responsible for the child's management. Cut to live action as the speech pathologist interacts with Mrs Beck. TERRY My role, and we're going to have a nice long relationship, is to see Michael now at this first session and follow him through right until he is 12 years. They continue their discussion. VOICE OVER At the first speech therapy counseling session, which usually occurs at 3 to 6 months, the parents are provided with information and support regarding their child's feeding, speech and language development. (MORE) ----------------------------------------------------------------------------------------------------- 9. VOICE OVER (CONT'D) The session aims to explain palatal function and its relationship to speech production, and to provide strategies aimed at minimising the impact of the cleft upon the child's resonance and articulation. TERRY The soft palate is really important in speech because we don't want him to end up with nasal resonance. MRS BECK What exercises now can I be doing? TERRY There are some you can do now. We often encourage blowing type exercises. Like blowing mobiles and pieces of tissues. And therefore to be able to blow you need to close off your soft palate so it will encourage his soft palate to close off. VOICE OVER This session also aims to reiterate the importance of maintaining good hearing and to reassure the parents about normalcy of other developmental aspects as well as develop a positive working relationship with the parents allowing them to air any concerns regarding speech, language, feeding and surgery. INT. HEARING LABORATORY Michael is being tested for hearing. VOICE OVER In almost 80% of cases infants have a hearing deficiency due to a collection of fluid in the middle ear called Otitis Media with effusion or glue ear. This fluid impedes hearing and if left unchecked, the subsequent speech development of the child. INT. HARVEY COATES ROOM - DAY Mr Coates, is examining Michael's ears. ----------------------------------------------------------------------------------------------------- 10. VOICE OVER Medical treatment may be successful but if there has been no improvement, surgical intervention may be necessary. Cut to live sound as Mr Coates shows Mrs Beck a container of grommets. MR COATES Here are the grommets that you have in your ears and you can see all the various sizes in there. (pause) What we're going to do now is have a peek at your ears and see what your grommets look like. Mr Coates looks in Michael's ear. MR COATES (CONT'D) And that grommet is in tact and dry, clean, perfect. VOICE OVER Grommets stay in place for 3 - 9 months, and there is a higher need in cleft palate children for subsequent sets of ventilation tubes. It is important that this procedure is performed by an ENT specialist who is experienced with the management of children with cleft palate and their associate problems as some Infants may have additional problems with their airway following closure of their cleft palate. This is related to the fact that upper airway obstruction may be present with a deviated nasal septum, allergic swellings in the nose, large adenoids, large tonsils, or any combination of these factors. INT. SPEECH PATHOLOGY CLINIC Michael, now a year old, (August 2000) is being assessed. VOICE OVER The child is again reviewed at age 12 months where early assessment of their palatal function, speech and language development is undertaken. The child is then routinely seen on an annual basis but more regular reviews are provided if necessary. (MORE) ----------------------------------------------------------------------------------------------------- 11. VOICE OVER (CONT'D) Between the ages of 2 and 5 a complete assessment of the child's palatal function is undertaken and in about 20% of the cases, more intensive speech therapy is provided. INT. VIDEO X-RAY MACHINE Another child (about 5 years old) has a video x-ray performed. We see the soft palate failing to close. VOICE OVER If this therapy fails to resolve any speech problems the speech pathologist and plastic surgeon conduct instrumental analyses of the child's velopharyngeal function using the techniques of lateral video x-ray. INT. NASENDOSCOPY ROOM A nasendoscopy is being performed by Mr Gillett. VOICE OVER Or in some cases the more intrusive nasendoscopy is performed. In about 10% of all cleft patients the closure and repair of the cleft may result in a soft palate which is too short or immobile to perform its primary function of closing off the oral cavity from the nasal cavity during speech resulting in hypernasality. In these cases a Pharyngoplasty maybe required. INT. GRAPHICS VOICE OVER Usually a Jackson sphincter is done but in suitable cases a superiorly based pharyngeal flap is used. INT. DENTAL ROOM Dr Baker talks to camera. DR BAKER The major aim of our treatment protocol is aligning the maxilla to allow definitive primary surgery. We aim to reduce the number of secondary operations to a minimum but all cases are reviewed regularly in the combined cleft clinic and if (MORE) ----------------------------------------------------------------------------------------------------- 12. DR BAKER (CONT'D) necessary, procedures such as lip scar revision, Abbe flap or secondary rhinoplasty are scheduled. INT. CLINIC TWO A smaller clinic in a dental room is running. VOICE OVER Ongoing reviews continue until the unit considers it has achieved the best possible result for the patient. In 1981 the unit commenced secondary bone grafting as part of the treatment. These clinics decide what dental or orthodontic treatment is necessary prior to bone grafting and to assess the most suitable age at which the graft should be placed by the plastic surgeon. Around an X-ray on the wall the Paedontist's discuss treatment. VOICE OVER (CONT'D) With the wide spread of dental specialties the paedodontists and orthodontists can invite the opinion of the prosthodontists, periodontists, oral and plastic surgeons as to the long term prognosis of whatever type of treatment they maybe considering. INT. CHILDREN'S WARD Mr Albert Tan inspects a 12 year old pre bone graft patient and does preoperative work. VOICE OVER Once these decisions have been made the patients are given a thorough preoperative periodontic work up including the use of chlorhexidine mouthwashes to produce a surgically clean operative area. We consider this is a significant factor in the successful results. INT. PHOTOGRAPHS Photographs illustrate various cases to illustrate bone grafting. ----------------------------------------------------------------------------------------------------- 13. VOICE OVER Secondary bone grafting is carried out between the ages of 8 and 12 years prior to the eruption of the permanent canine. The technique is based on that developed by Bergland and Abyholm in Oslo. Cancellous bone from the iliac crest is placed in the cleft area. Alveolar bone grafts are also performed in all cases where there is a bony defect in the alveolus. Cut to Bergland scale. VOICE OVER (CONT'D) Five year follow up of 200 cases shows a 95% success rate. (pause) Following bone grafting the patient is seen regularly in the dental clinic until ready for definitive orthodontic treatment. INT. CLINIC ONE A 16 year old Kalgoorlie boy with a displacement apparatus attends the clinic. VOICE OVER In the final stage of review between 14 to 18 years, any secondary rhinoplasty is carried out when needed. Severe basal class II or class III cases which cannot be successfully treated by orthodontics are referred to the craniofacial clinic for osteogenic distraction or orthognathic surgery. Mr Gillett adjusts the apparatus. VOICE OVER (CONT'D) Following any final prosthetic work, implants or other cosmetic dentistry is completed, the patient is finally ready for discharge. INT. GRAPHICS IN THE 25 YEARS FROM 1970 TO 1994 THERE WERE 640 LIP AND 752 PALATE OPERATIONS. Those cases have required the following secondary procedures: ----------------------------------------------------------------------------------------------------- 14. LIP REVISION 15% SECONDARY RHINOPLASTY 12% PHARYNGOPLASTY 11% INT. PHOTOGRAPHS Vision of 10 consecutive cases operated on in 1983. VOICE OVER These 10 complete unilateral cleft lip and palate patients were all operated on in 1983. The only secondary procedure performed was a lip revision in this case. INT. MONTAGE OF THE UNITS AT WORK. VOICE OVER (CONT'D) Since 1987 when a new wing of the hospital was opened, the dental, speech, ENT, plastic and neonatal units have been located in close proximity to each other. This has made it easier to work and consult together, exchanging ideas and critically reviewing results. (pause) The combination of these disciplines within the hospital and being able to assess changes along the way has been the most important aspect in the long term success of this unit. (pause) This team approach and interaction between the various specialties as well as long term follow up has led to Princess Margaret Hospital to achieve results equal to the world's best standard of current practice.