By Carmen Ramos-Irizarry, MD

Taking a stand on firearm safety and prevention

Firearm injuries are the second leading cause of death in children, behind motor vehicle accidents. Tragically, when a child attempts suicide with a firearm, they are “successful” 95% of the time, making firearm accidents and deaths a top priority for pediatric surgeons. The laws vary from state to state on the role that doctors can take on educating and discussing firearm choices with families, but we are now taking a stronger stance against this incredibly dangerous threat to children.

In Florida, for example, we are not allowed to talk to patients or families about firearms, so we’d like to share data on suicide attempts and the damage for those who survive.

So, the American Pediatric Surgical Association recently released a policy on firearm injuries, endorsing universal background checks including for private sales, which is a gap in the law. They are advocating for restricting assault weapon purchases by children and raising the minimum purchase age of firearms to 21. Finally, my colleagues and I want to encourage and advocate for schools to train their staff on bleeding control, in the wake of mass (and smaller) shootings.

Preventing opioid use in children stemming from post-op prescriptions

It’s startling, but one in 8 children has reported trying opioids by high school. Sixty percent of teenagers who use heroin say they first started by misusing 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 post-op prescription, and education surrounding opioid choices for families.

A task force of surgeons recently published the first guidelines for opioid prescriptions after surgeries for children and adolescents, filling a gap that before had only published research relating to adults. This is meant to combat 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 replacing routine opioid prescriptions for children post-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 necessary for pain control, such as in more severe and major surgeries, the guidelines recommend a prescription of three days, as any longer than that increases the risk of addiction. More major surgeries like this might include procedures that require opening the abdomen or thorax, and/or a larger incision.

But it’s not just about changing the prescription, but rather the education surrounding it. It’s all in the expectations and education of the patient and their family ahead of the procedure. We have to educate the parents, family, and the patient to provide expectations before and after. For example, if you have a patient with a hernia repair, you may say to them, ‘This isn’t going to be too painful, and you will need Tylenol and Motrin at home, and I’ll give you a scheduled regiment.’ If you say, ‘Oh, it will be painful,’ some will go back to the ER saying they need narcotics. The new guidelines and a focus on proper education on pain management will eliminate the ER visit.

Finally, there is a necessity to educate the entire care team on the risk of opioid addiction from post-medical procedure prescriptions, particularly in Florida, which has high rates of opioid use in teenagers. Nurses, surgeons, and anesthesiologists should all be aware of the risk of prescription misuse. Florida health care providers can check a website to screen for prior misuse of narcotics, including who prescribed them and the last time the patient used them.

Responding to child abuse with a multi-disciplinary team

The Florida child abuse situation is bleak, as evident by the Children’s Advocacy Center of Florida’s 2018 statistics:

• 35% is sexual abuse

• 27% is physical abuse

• The rest is neglect

• Just over a third of abuse victims are ages 0-6

• 60% are female

While it’s common for pediatric surgeons to treat child abuse victims in need of trauma-related surgeries, what’s new and increasingly important is their ongoing involvement on the care team, along with nurses, pediatricians, social workers, the family, and child protective services. We are pushing for advocacy through this structured and multi-faceted team, rather than a more disjointed approach. Because we are very thorough in our trauma evaluation/physical exam, we identify and treat findings that are not immediately recognized by pediatricians.

My hope is that a standardized tool to screen for child abuse when children arrive in hospitals and trauma centers will help. We support data accrual on abuse screening and diagnosis into a trauma registry.

Dr. Carmen Ramos-Irizarry, a pediatric surgeon at KIDZ Medical in Naples, is a Councilor of The American Board of Surgery (ABS), the national certifying body for general surgeons and related specialists. For more information, visit www.kidzmedical.com/provider/carmen-ramos-md.