By Carmen Ramos-Irizarry, MD
Take a stand on gun safety and prevention
Gunshot wounds are the second leading cause of death in children, behind traffic accidents. Tragically, when a child tries to kill himself with a gun, he “succeeds” 95% of the time, making gun accidents and deaths a top priority for pediatric surgeons. Laws vary from state to state on the role physicians can play in educating and discussing gun choices with families, but we are now taking a stronger stand against this incredibly dangerous threat to children. .
In Florida, for example, we are not allowed to talk to patients or families about guns, so we would like to share data on suicide attempts and damage for those who survive.
For example, the American Pediatric Surgical Association recently released a gun injury policy, endorsing universal background checks, including for private sales, which is a loophole in the law. They advocate restricting the purchase of assault weapons by children and raising the minimum age for purchasing firearms to 21. Finally, my colleagues and I want to encourage and advocate for schools to train their staff in bleeding control after shootings.
Prevention of opioid use in children resulting from postoperative prescriptions
It’s surprising, but one in eight children reported trying opioids in high school. Sixty percent of teens who use heroin report having started abusing opioids, sometimes prescribed after surgery, including Percocet, Hydrocodone and similar drugs. My colleagues and I are working to stop the problem before it starts – with that first postoperative prescription and education about opioid choices for families.
A task force of surgeons recently released the first guidelines for prescribing opioids after surgeries in children and adolescents, filling a gap that previously had only published research that focused on adults. This is aimed at tackling the practice of routinely prescribing opioids to children after surgery, as they would to those over 18.
The recommendations in the new guidelines essentially promote the replacement of routine opioid prescriptions for children after surgery with a schedule of ibuprofen and acetaminophen. This is the case for mild and moderate pain levels in the recovery period. If opioids are needed to control pain, such as in more severe and major surgeries, guidelines recommend a three-day prescription, because any longer than this increases the risk of addiction. Larger surgeries like this may include procedures requiring an opening of the abdomen or chest and / or a larger incision.
But it’s not just about changing the prescription, but rather the education that surrounds it. It is all about the expectations and education of the patient and their family before the procedure. We need to educate parents, family and patient to provide before and after expectations. For example, if you have a patient who has had a hernia repair, you can say, “It won’t be too painful, and you’ll need Tylenol and Motrin at home, and I’ll give you a scheduled regiment.” ‘If you say,’ Oh, that will be painful, ‘some will go back to the emergency room saying they need narcotics. The new guidelines and emphasis on proper pain management education will eliminate the emergency room visit.
Finally, it is necessary to educate the entire healthcare team on the risk of opioid addiction in post-intervention medical prescriptions, especially in Florida, which has high rates of opioid consumption among adolescents. Nurses, surgeons and anesthetists all need to be aware of the risk of prescription misuse. Florida health care providers can visit a website to find past drug abuse, including who prescribed them and the last time the patient used them.
Respond to child abuse with a multidisciplinary team
The child abuse situation in Florida is grim, as evidenced by 2018 statistics from the Children’s Advocacy Center of Florida:
• 35% are sexual abuse
• 27% are physical abuse
• The rest is negligence
• Just over a third of victims of abuse are between 0 and 6 years old
• 60% are women
Although it is common for pediatric surgeons to treat abused children requiring trauma-related surgeries, what is new and increasingly important is their continued involvement in the care team, with nurses, pediatricians, social workers, family and child protection services. We advocate advocacy through this structured, multidimensional team, rather than a more piecemeal approach. Because we are very thorough in our trauma assessment / physical exam, we identify and deal with findings that are not immediately recognized by pediatricians.
I hope that a standardized tool to screen for child abuse when children arrive at hospitals and trauma centers will help. We support the accumulation of data on the detection and diagnosis of abuse in a trauma registry.
Dr Carmen Ramos-Irizarry, a pediatric surgeon at KIDZ Medical in Naples, is an advisor to the American Board of Surgery (ABS), the national certification body for general surgeons and allied specialists. For more information, visit www.kidzmedical.com/provider/carmen-ramos-md.
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