Dr. Alyssa M. Burgart - Peri-Op Teens: Adolescents, Parents, and Surgical Care

of anesthesia and surgery. This morning's talk is actually part of our health and wellness lecture series. And it is my great pleasure to introduce our guest speaker this morning, Dr. Elisabeth Bergart. Dr. Bergart is a bioethicist and clinical associate professor of anesthesia at Stanford University. She obtained her medical degree and a master's in bioethics and health policy from Loyola University in Chicago. She also completed her residency in anesthesiology at Loyola and then went on to do a fellowship in pediatric anesthesia at Stanford where she has since been on staff at Lucille Packard, Lucille Packard Children's Hospital as a pediatric anesthesiologist. Clinically, Dr. Bergart specializes in pediatric abdominal transplants in anesthesia. She also holds a number of leadership roles pertaining to bioethics at both Lucille Packard Children's Hospital and Stanford University. She's the medical director of clinical ethics at Lucille Packard Children's Hospital and holds several advisory roles and sits on a number of bioethics committees at her hospital and Stanford. Her ethics interests include pediatric ethics, orkin transplantation, communication skills, disability rights, women's healthcare access, adolescent decision making, ethics education and excellence in ethics consultation. Good morning, Dr. Bergart. Thank you so much for joining us to brighten early this morning and I will turn things over to you. Good morning, thank you so much for having me. I'm particularly delighted that both the anesthesiologist and surgeons were interested in this talk. It's certainly relevant to all of us and the work that we do in taking care of children into adulthood. I use she, her pronouns. I'm happy for this to be casual, if you have questions that come up during the case that you'd like to put into the chat or that you'd like to vocalize, go right ahead. I have no financial relationships related to this work. I'm not a lawyer, I do comment on laws related to adolescent care. I'd also like to acknowledge, I'm giving this lecture physically in California on Moeckma, O'lonelyland and most of you are in our on pataket, Masaachu-eset land. So the focus of today's talk, we're going to discuss the impact on periodoperative care amongst adolescents and the way that adolescent development can affect our interactions with them. The difference between consent and us and for teens depending on the issue that we're discussing, what rights we might have, depending on where you practice, which is especially important for those of us who may practice in different states during our time as physicians, nurses, social workers, et cetera. We'll briefly touch on communication and trauma-informed care and talk about some special situations, pregnancy testing and pregnancy, transgender care, as well as child abuse, sexual abuse and child sexual exploitation. Those can be very difficult topics to talk about and so if those are things that are troubling for you and you need to drop off at any point, of course, please do. Winter is coming. We are still in a pandemic. The flu is coming, so just want to acknowledge, I know all of us, as well as our patients, have been going through a lot this year and teens have been impacted in particular. So they've had their at risk for a number of issues during their adolescence and some of those are just particularly heightened during the pandemic and I'll touch on those. So teens in particular rely very heavily on their friendships and their relationships. It's very human aspect of what we do and teens are struggling, I think, in pretty unique ways, even worse so to adults. So in terms of development, adolescence is this very kind of nebulous idea, when does it start, when does it end? And certainly it's something, sometimes called the second toddlerhood because there's such rapid, emotional, physical and psychological development. And so it starts very early in terms of when do we start seeing the first signs of pregnancy as the first signs of adolescence is quite early and then it goes on well into what is legally considered adulthood in most of the United States so well into the 20s and mid to late 20s. And so again, we're seeing really significant changes. In terms of typical development, there are some good reasons why teenagers act the way they do and why they make certain types of decisions and have certain types of risky behaviors and part of that is that they're in the midst of this incredibly dynamic developmental change that's going on in terms of physical changes. That includes changes to the brain in terms of green matter in terms of how much pruning is going on and in particular, the area is related to executive function, take quite a long time to complete their development. This means that teens often can make decisions that may be highly intelligent or maybe specific reasons. They may make those decisions very rapidly and that means that it can contribute to risky behavior and they can also have very extreme emotions. One of the things can be challenging is that during this massive developmental change that we see, there's this very artificial line that is placed generally at age 18 that says well you've gone from being a child to being an adult but developmentally of course that person is probably pretty similar on their 17th, the last day of their 17th birthday and the first day of their 18th birthday. So for neurotypical children though, that's where they're going to gain a number of legal rights automatically and no longer be under the explicit care of their parents necessarily. However, there are some exceptions, some legal exceptions that allow patients to have certain rights before they turn 18 and we'll talk about some of the specific ways that teens may specifically consent for themselves for certain procedures or for anesthetic care. And then of course even though this line gets crossed, we know that the brain's not fully developed so it means that in my work that I do with young adults we continue to address the need of the issues that come up with patients in adolescents as they move into young adulthood. But we're really transitioning during kind of around this period of this line is this transition between making decisions in the best interest of a patient which is much easier when they're a baby and a toddler and they can't really express the things that they need for themselves and reason through decisions versus moving towards a more autonomy-based standard which is generally how we think of the approach that we take to adults. One of the things that can be really useful when you're having conversations with a teen or with a young adult patient is really getting a sense of what does adolescent capacity mean and how can we use some tools that are useful in in some adult populations to help us understand the maturity level for example of an adolescent who's facing perhaps a difficult medical decision. And so when I'm working for example at the adult hospital and I'm helping to assess whether a patient has capacity to make a certain decision I really think about these four domains. So is the patient able to understand the different situations that they've been presented with or the different medical choices they've received? Have they, can they reason through those issues? Can they appreciate the outcome of the decisions that they're being presented with and are they able to express a choice? Those aren't the only things that go into decision making but those are kind of a nice way to break them up when we're thinking about them. These are things that we can use in adults who have for example altered mental status or intellectual delays that are present, patients who have psychiatric disorders but teenagers are not people who have an altered mental status or if they're neuro-typical they don't necessarily have any sort of intellectual delay and they're not psychiatric patients. So some of these things can be challenged by the fact that you have somebody who's on a normal developmental trajectory and just happens to be in an early phase when they're making those decisions. And I think the other thing that I find in my work with pediatric providers, it can be hard to remember that adults are allowed to make absolutely terrible decisions for themselves if they're able, if they have the capacity to do so. And so that can be I think a challenge when we, when I don't know about you all but I'm, you know we continue to take care of patients into young adulthood and that can be a stressor for clinicians when their teens become adults and are able to make decisions that the team doesn't necessarily agree with. I get asked a lot if teens have rights and the rights that they have in the United States are somewhat limited. We as the country did participate in the United Nations convention on the rights of the child. And if you ever are interested in really getting down to the nitty gritty of what are the human rights of children, this document is very extensive and goes into many different aspects of the humanity of children. Madeline all right help to write this. It has never been ratified in the United States. So and a big part of that is because it would very much upset the incredibly complicated set of state laws that currently address child health in the United States. And so it makes this somewhat hot button issue. And it's not been something that the federal government has been interested in putting a lot of attention into. Teams do have a right to live and that's something that you see throughout state laws about adolescent care is really focusing, trying to focus on their dignity. We certainly as clinicians should respect adolescents. I think in our culture they're content to be a dismissal of teams as oh well they're young, they don't really know what's going on or well. You know they can't really understand what's happening. And I think in many times it does come down to what sort of communication are we using and are we meeting patients where they are? Are we meeting them in their developmental stage and ensuring that they're getting the information and they need to make decisions? And those can be things that can really help to foster the relationship that we have with our patients and ensure that our teams are having their human rights and their dignity really, really supported. Sometimes teams get to sign their consent forms. So we'll talk about a few times when that may happen. So mature minor is a term that I think is used frequently and not always totally understood. There's an ethical determination of that if someone's mature. Oftentimes if they're able to demonstrate that they have capacity, they're able to demonstrate that they have a solid foundation and the decision that's being made. But there's also a number of legal requirements that go into if someone will be designated as a mature minor and those might be by state statute. They might be by a judicial ruling and really each state can have their own requirements about how it is that you're going to determine maturity. And so there is these wide array of situation and state dependent rights. Massachusetts has a number of rates for adolescents that are very similar to California. Where I practice. But we see that from state to state and from territory to territory, whether you're having a question about general medical care or whether the patient is having a reproductive health care question, if the question is related to mental health, if the question is related to child abuse, these patients may have a really wide array of smattering of rights and a smattering of ability to consent to things. And sometimes because of the way it works out, it doesn't come across necessarily as logical. And so it's important for us to understand what rights they have in a particular way of it is that we're practicing to make sure that we're honoring those rights. But also to do our best to really honor teens through these sometimes very difficult situations. So I'm specifically going to cover in the United States what are the states that actually have statutes specifically related to when a person can make general medical care as a minor. So it's really all over the place. So in Alabama, a minor has to be 14 years older or older to have consent authority. And that's it. They just have to turn 14. However, they're not allowed to consent to an abortion in Alabama. And that's the other thing that we see across the United States is this tension between allowing patients, for example, in California and Massachusetts where a patient cannot consent to general medical care at 14 or 16, but can consent to any sort of reproductive health care. But what we see is some of the states that have a major minor statute, they put specific limitations around reproductive health health care specifically. So in Arkansas, it's really any age where the informed consent standard is met. It really leads it up to the clinician to help determine that. And in Idaho, the patient just needs to meet an informed consent standard. So you sort of see this language from state to state that can be quite similar. Kansas is interesting. A patient can be 16-year-old or older to consent, but only if a parent is not available. Now what this does mean is that, for example, 16 patients who are 16-year-old or older, who, for example, run away from home, can still consent to their own medical care. And Louisiana, there just needs to be, there's no minimum age requirement, but the clinician has to believe that the treatment is necessary. Which certainly I would hope that the clinicians believe that their offering is necessary regardless of the patient's age. In Montana, you just have to graduate from high school or turn 18. So if you don't graduate from high school but you turn 18, then you still get those rights. Nevada is interesting because the patient has to believe that the treatment is, sorry pardon me. In Nevada, the patient needs to meet the informed consent requirement and then the health care provider needs to believe that there's a danger in not providing the service. And it's a little unclear to me if you're practicing in Nevada how the clinician determines that, but the state sort of leaves it up to the clinician. And Oregon has a really interesting situation. So Oregon says, okay, you, my energy needs to be 15 years old and you can have consent authority. But in the early 2000s, there was a case of a teenager who was over age 15, who developed a hematologic cancer, who was a Jehovah's Witness and refused blood transfusion. And his parents crossed out the part about consenting to blood transfusion and they said that our child isn't a germiner. This isn't relevant. He refuses blood. And that case was actually taken to court and the judge in the case said, actually, they actually compelled the patient to be transfused against his wishes. So I think what's interesting is what that says is that in Oregon, you have the right to consent, but you might have the right to refuse. And those things really should go together. So it can be, I think, somewhat confusing for patients as well as for clinicians. Pennsylvania, we see the same language about, as we saw in Montana, in terms of graduating from high school. South Carolina patients can consent to general medical care, but not procedures. So not able to consent to the things that you might be offering in terms of anesthesia or surgical procedures. And so again, this is just for when these are the only states where a specific condition will render a minor able to make all general medical care decisions for themselves. This map is totally different if you look at mental health care rights, if you're looking at substance abuse treatment rights, if you're looking at the right to an abortion, if you're looking at the right to make any sort of reproductive health care decision. So specifically, Massachusetts law, like I said, has some similarities to California law in that there are some specific conditions that lead your patients to be able to make their own decisions. So for example, if one of your patients is a minor but is married, if that person is the parent of a child, they may make their own decisions, as well as decisions for their own children. So they have parental rights. If they remember the armed forces, if the patient is pregnant or believes themselves to be pregnant, as well as if they're living separately from their parent or legal guardian, and then as well as if they have a oftentimes, these are any sort of public health disease, oftentimes sexually transmitted diseases that need to be treated. There is a requirement in Massachusetts for parental consent for abortion. If the patient does not want to obtain parental consent, they have to go to court and be determined to make sure to make that decision without their parents' involvement. And then there is specifically a ban that was recently placed on gay and gender identity conversion therapy for children under 18, which is a real landmark law. So in terms of a scent and consent and parental permission, and what do I do if I have, I think oftentimes, clinicians are very concerned about what do I do if there's disagreements at the bedside between the parent and the patient. Thankfully, most of the time when parents present with their adolescent patients, most of the time we see these families coming together to make a decision together, we oftentimes see families that are allowing their team to gain independence and to be participating in those decisions more fully. Other times we see, I would say it's more rare that I tend to see families where the parent is insisting on particular treatment or categorically opposed to particular treatment. But teams really need to be involved in understanding the risks and benefits in the alternatives to treatment. Even very young children are cognizant of their own body and what is happening to their body. And so it's very important that we engage adolescents to a great degree. Something else that I will point out is that because of inherent ableism in our medical training and in medicine in general, oftentimes you may have an adolescent patient, for example, who has a physical disability or other disability, that sometimes can make it so that clinicians don't actually recognize that the patient has high intellectual capacity to participate in complex decision making. And so just being certain that we're engaging patients to the greatest degree possible. So generally if patients agree to move forward with a procedure, the parents are in alignment, which is what I would say happens most of the time, we're going to proceed with care. We're going to proceed with that surgical care and with that anesthetic care. But however, if the parent consents to treatment, but a patient refuses non-emergency care, we really need to talk about canceling that case if we are not able to come to a resolution with that family. And the reason I say that is because not recognizing what the alternative is, is that we're not going to be holding down 16-year-old patients and forcing them to have surgery that they don't want or forcing them to have an anesthetic that they don't want. It's incredibly harmful. And oftentimes I feel that when I have gotten consults, for example, on this issue where they say, well, we just really think this patient needs this procedure. Or they really need this anesthetic. We need to work together and really maximize our communication skills so that we can come to a resolution with a patient and with a parent to really take the best care possible of the patient without using coercion. This is just a quote from the American Academy of Pediatrics, I think, is important. I think it's important for patients really of all ages and it just becomes even more important as patients get older, which is really that if we're going to ask a patient their opinion, we should actually care what their answer is and not just ask things tacitly. If there's a choice, present a choice. If there's not a choice, don't present a choice. So really being careful of what we say and that we shouldn't be using deception. Again, adolescent treatment refusal is something that can generate a lot of anxiety, sometimes amongst clinicians. I think one of the things that's really important to think about is how urgent, how time sensitive is the decision that needs to be made. First of all, if a teen has the right to the legal right to consent or to refuse treatment, then we need to pay attention to that patient. Even if their parent disagrees, their parent actually doesn't have the legal ability to block their ability to make that decision. And so being clear on what decision is being made and what the right to your patient has are really incredibly important here. If you have something that's in emergency and you don't think the patient has capacity because of the behaviors you're seeing, because of their inability to participate, for example, in the decision, then it may be that you're going to provide that care based on a presumption that the patient would like to remain alive. If it's an emergency treatment that's really going to preserve life and limb, then often times we would proceed with that treatment. For things that can be delayed safely, we really need to engage that patient in that process of coming to a decision. And again, it can be very difficult when these things come up in the morning of surgery when everyone's trying to get that first case start going and suddenly it becomes apparent that there's a significant disagreement in the process. And so if you have a family about whether to proceed, we just unfortunately sometimes need to either delay that procedure or reschedule it. In terms of a right to privacy, teens' concerns about their confidentiality, about their right to privacy, can have a really significant impact on the health care that they receive. So if you want teens to be honest with you, you want them to disclose health care information that really might change the way you manage their care, then it's important that they understand how you're going to respect their decision making, how you're going to respect the information that they give you, as well as what are the limits of that confidentiality. And pointing out those things before a disclosure has been made can really help to ensure that a patient doesn't feel that they've been duped into giving you information that they feel may harm them in the future. There certainly are some federal laws that protect adolescent confidentiality. This is oftentimes limited by those state laws. So depending on which rights are protected for a patient in your state, then that's going to affect what HIPAA and FERPA have to say about what rights your patient has for maintaining confidentiality, for example, of data. And really, we shouldn't promise confidentiality if we can't provide it. So being really honest and explicit about what you can and cannot keep confidential is really, really powerful. So just to put into perspective for HIPAA, for example, any other reason this is really important is the 21st century Cures Act, which I'll talk about next. If the patient's acting as their own representative, so let's say in Massachusetts, the patient is asking for reproductive health care services or they're asking for treatment for venereal disease, for example, then those are things where the patient is acting as their own personal representative. And they're actually entitled to keeping that information confidential from their parents, because the minor would be acting as their own individual. But for general medical care, things where the parent is consenting, then really both of them have the right to accessing that information and the information can technically be disclosed to their parent. So this is something that's coming down the pike. I had actually expected it initially that this would be released on November 1st for adolescent data, really data, you know, quick data sharing. You know, patients are going to have access to almost all of the notes we write, almost all of the test results pretty much immediately within our healthcare IT systems. And this is created some really unique challenges for data management in relation to adolescent healthcare. And the reason is because again, that smattering of laws and what information can be disclosed to the parents and what information needs to be kept confidential. So people in healthcare IT have been working really, really hard trying to come up with ways to create barriers so that parents are not able to access information that teams have a right to keep confidential. Talking to parents as pediatric providers, I think that most of us are much more comfortable with this aspect than many of our adult care colleagues. So talking to parents is a typical part of our process. I think what can be difficult is as teams, you know, gather their education, they're getting older, they're developing as decision makers. You're seeing that reduction in the participation of parents or an insistence on the participation of parents that sometimes may be intrusive. When we're asking to talk to a patient separately because we're going to collect sensitive information, it's pretty typical that we would ask for a parent to be out of the room so that we could do an accurate assessment of the patient. Because they may not want to disclose things in front of their parents that they might disclose to us as healthcare providers. This is really an opportunity to explain to parents that, you know, this is an opportunity for their child to gain independence. And, you know, when their child was a toddler, of course, they would have provided a lot of support, you know, would have tried to help them to learn to grow, to learn to have those new skills that they were gaining. And this is a new opportunity in a different developmental stage of life in terms of, you know, giving that patient a little bit of space and helping them to have more adult relationship with their healthcare providers. And again, just being certain that we're clear on what's confidential, what information would be disclosed to that parent versus what would not. That said, as pediatric providers, I think it's also very important that we are conscious of what has been going on in the news over the past several years in regards to physician sexual assault, for example. The Larry Nasser case has made it very challenging. And this is someone who actually assaulted patients while their parents were in the room sometimes. And so there may be, depending on what cases are going on, especially in the immediate surrounding media environment, there may be times when parents are explicitly a little bit more reticent to leaving their child with a healthcare provider. I think just being thoughtful of that and addressing concerns and coming up with systems that really ensure we're supporting adolescents and parents appropriately. I'm a big fan of communication. I'm a relationship centered communication facilitators through the Academy of Communication for Healthcare. And I'm really, really passionate about using trauma-informed care as well as just using really respectful, respectful dialogue with our patients and our families. So all of us can improve our communication skills. This is a lifelong learning opportunity. I have a lot of fun when I'm facilitating people across their, you know, from early in their career to the end of their career in terms of communication skills. These are things that we can use at home. These are things we can use with our patients. So your adolescent patients really deserve your effort and attention. And you can have a really, they're really fun. Adolescents are fun. They're interesting. They're going through really, really big changes in their life. And we have an opportunity to have really, really rich and meaningful relationships with them. Even if our relationships as perioperative providers are sometimes quite short, they can be really meaningful and really powerful. When we're going to talk to teams about difficult situations, when we're going to talk to them about sensitive topics, it's important that we be extra attentive. And that we take those questions very seriously. We want to listen very attentively, we're going to be present with our patients. Again, I just, I cannot express enough how important it is to be certain, you know, if you're going to meet, if when I meet with a student, for example, there are some limits to the confidentiality I can provide to a student. So I often explain that ahead of time. And it's the same if I'm working with an adolescent patient who, if I'm going to ask these sensitive questions and they may disclose something, I try to just make it clear ahead of time. There are a few scenarios in which my obligations as a mandatory reporter would influence my ability to keep something private. It's important to use open-ended questions to be non-judgmental in our responses. We want to invite teams that they can ask questions as well. And also, if, again, if a patient has a positive pregnancy test, if they're admitting to a list of substance abuse, recognizing that this may, for example, if this is in the period of an environment, may lead to a cancellation of a non-urgent surgery, may affect their surgical or anesthetic risk. And so being prepared to answer those answer questions about the consequences of those things. And so again, I think what can be challenging is that we get certain kinds of testing or we ask some questions in a somewhat wrote way. But if we're not prepared to respond to the situations that don't happen every day, sometimes I think we can be caught off garden. It can be a little distressing for us as clinicians. Trauma-informed care actually lives through Boston Children's website. You guys have a number of really wonderful resources in regards to trauma-informed care. And one of the things that's really important when we're thinking about what does that mean is that patients of all ages may have experienced, whether they're adverse childhood experiences or other forms of some type of trauma before they see us. We don't know what experiences that patient has had before they come to see us. And so by having a trauma-informed mindset about collecting that information, means that what we can have is a positive and positive. We can avoid accidental missteps with our patients that can make them feel really uncomfortable. And especially because if we put a patient in a position where they do feel very uncomfortable, they actually may not come back for additional medical care from anyone and let alone from you. And so really trying to promote an environment that's safe. We always want our patients and their families to feel safe at the hospital. What is the language that we're using? How can we attend to their comfort? We're making sure that we have consent before we ask questions, consent before we touch a patient, and ensuring that if we're going to do a procedure that we're really giving the patients the information they need by asking them what it is that they would like and what information do they find most helpful. I think the other thing is doing exams, especially even sensitive exams, can be totally routine for us because this is just a routine part of our practice. But for the patient, it may be their first experience, and it may be triggering for other traumatic experiences that they may have had. A minute specifically skip ahead to pregnancy testing and labor epidurals as well as some medication reactions. So parents don't always know about teen's healthcare choices and for a number of the issues that we've discussed before. Especially in states like your state where a teen might be able to have consented to receive, make their own contraception decisions, but it isn't allowed to consent to their ungeneral medical care. So when in our pre-op process, I mean our pre-surgical process, if we're primarily talking with the parent to get all of the information, we just have to be, we just have to recognize that we may miss out on some important healthcare questions and information that may affect our care. In terms of pregnancy testing, certain organizations have routine pregnancy testing for all patients down to a particular age or all patients who have a physical ability to become pregnant. It's important to recognize when you work in a state where a positive pregnancy test actually confers a number of rights. It's important to recognize that before you disclose a result and that comes down to a negative result or a positive result. And really having a plan as an organization, how do you respond to a positive result? Do you have training how to disclose that positive result in a way that is supportive of your relationship with the patient? Are you ensuring that if there is a disclosure, if the patient would like to disclose to their parents, how can you help facilitate that in a supportive way that keeps the patient safe? And if the patient does not wish to disclose and it's their right to keep that information private, how are we, if we're going to cancel their elective surgery, for example, how are we going to manage that with the parent without disclosing the result? And this can also be a real tricky situation, especially when it comes up in pre-up on the day of surgery. And so you may have to do some careful navigating. And it can be challenging because sometimes you're in a position where you think, well, I don't feel comfortable lying to the parents, but I absolutely cannot tell the parents the result of this result. And so oftentimes I recommend working with the team to determine how to disclose that in a way that will not put them in a difficult situation when they go home. In terms of pregnancy test refusal, you may have patients who just refuse testing. And if it's not going to change our management, I think it's very important for us to consider, do we really need that result? Is this something that's going to lead to cancellation of a elective procedure? Or is this something where refusal is appropriate and acceptable? I think, again, having a conversation with your patient about why they've made a refusal can help you understand what are the reasons behind that. And they may be reasons that you find completely satisfactory. And it may be that you learned something important about the patient that you didn't know before. I want to touch briefly on teen labor epidurals. It's something that I particularly find concerning in a number of states because there are a number of states that do not actually explicitly allow teens to make their own healthcare decisions during pregnancy. And what that means is that that teen, if they're a runaway or if they have a contentious relationship with their parents, if they don't have access to those resources of a supportive parent, it means that they may not be able to consent actually to treatment during delivery. And that means that their delivery is treated as an emergency. So there were a number of particularly difficult stories that came out of Ohio several years ago because of parents refusing to consent, for example, to labor epidurals for their adolescent patients, essentially as a form of punishment. There are a few of these states where children are still allowed to get married. And so if children are married in these states with these asterisks, then they could consent to their own medical care. But if they're just pregnant but not married, then they have not received that legal approval to make those decisions. And so unfortunately what happens in these states is that those children are essentially treated as unbefrended patients. So they're basically no one to help make decisions to be them and they may actually be explicitly punished through pain during childbirth as a form of punishment. For a number of medications for the anesthesiologists in the room, psichamides, peppertins, and contraceptive effectiveness, it's just important to recognize, do you actually know if your patient is on a hormonal contraceptive medication? Have you provided routine counseling to these patients that their medication may not be as effective as a form of contraception? And really just do you have a system in place to ensure that these patients don't fall through the cracks? Because you wouldn't want a patient to have an unplanned and unexpected failure of their hormonal or boric control because they weren't aware of a reaction to a medication that we might give. Even if it's something where you maybe are avoiding using psichamides, it is expensive. But even if you're avoiding using it for any number of reasons, having a plan in mind for using it is, I think, an important thing, especially if there's a drug shortage of any alternatives. Okay, we're going to switch gears a little bit to mental health. Screening for mental health care, obviously pre-op is not the most appropriate place for these things to be happening. And I am not suggesting that that be the primary mode of screening for mental health for our patients. But certainly before the day of surgery, all of our teen patients should be getting some sort of mental health screening. And the reason is because there are a number of patients who actually, for example, do complete some sort of self-harm who have been admitted for emergency health care services or who unfortunately die, but who actually have received some sort of interaction with the healthcare environment within 30 days of the event. And so it is incredibly important that we're ensuring we know that teens are struggling in particular now more than ever, and we knew this was an issue before the pandemic. So what are the signs that we're seeing? Are we seeing whether it's, is the patient has a patient disclosed to us that they have, for example, suicidal ideation or if they have self-harm behaviors? What sort of physical exam signs are we seeing? Does the rest of the team know about that? I actually diagnosed a, one of our gastroenterology patients who had presented for unexplained weight loss. And I said, oh, well, does she have access to therapy because she's clearly been cutting herself? And the GI team just hadn't noticed the patient had always worn long sleeves and it had really been effective at hiding that. And it wasn't until the day of surgery that it became apparent that she actually hadn't unmet mental healthcare need. So it's important to recognize, you know, what are the resources that are available? School closures have additionally made things really challenging for our team patients. There's an increase, increasing reports of patients feeling more unhappy, more depressed during the past year. And really feeling, many patients just, their basic needs are not being met. Obviously we understand that even more parents now have, there's food insecurity, there's healthcare insecurity. I know all of our children's hospitals are very concerned about the increasing number of patients who lack healthcare now or less partly healthcare insurance. And so I think just having this, oh, having this awareness during this time and however long the consequences of this pandemic go on can be really valuable in terms of ensuring that we don't miss an opportunity to intervene with a teen who may be struggling. There's been a, this is from the morbidity and mortality weekly report from just this week actually that emergency room visits are up really dramatically for specifically mental healthcare related reasons and they're up in five to 11 year olds up 24% and 12 to 17 year olds, they're up 31%. So really just being cognizant of that and ensuring that because what we see in both of these papers actually is that teens are reporting that they feel less supported by the adults in their life. And so as an adult healthcare provider, your support may be really valuable for them. Transgender care again, Massachusetts has specifically taken several stands in support of teens and transgender children in general. This is a quote from a parent of a transgender boy that I think is particularly insightful, you know without a doubt affirming healthcare providers can meet a difference between life and death. It's also essential for parents to learn as much as possible so they can effectively advocate for their child. There's a wonderful resource from human rights watch that was prepared with the American Academy of Pediatrics. And really demonstrating that there's a lot of resources that are available if this is a topic that you don't feel you have as much knowledge about. I highly encourage you to get to know what language can you use that is affirming for patients. What can we do to ensure that the experiences that patients have with the healthcare environment are positive are not traumatizing and will ensure that these patients feel comfortable coming back to us for additional care. I think that we all really want to support children through whatever it is they're going through and being able to use appropriate language when we're talking to our patients is a really important part of that. Misgendering using a child's dead name so the name that they associate with the gender that they do not identify with can actually be really harmful. And so it's important that we use the appropriate name and pronoun. So what the patient tells us they want to be called we should call them that it's not really about us. Now I'm going to move on to the last section on this which is on child abuse. None of these topics can be can be challenging for some of us. So child abuse is something that happens at all socioeconomic levels. It happens across all ethnicities. It happens across all cultures. It doesn't matter what religion you're in. There is abuse exists. And just because someone is educated absolutely does not mean that they will not potentially be abusive. And so it's just really important to have a sense of that that all children are at risk of child abuse. We certain so it's something that we just have to use. We need to be routinely screening for. And certainly if we see particular responses teams who are being abused particularly are going to have. Be at risk for certain symptoms. For example, that patient that I saw who had an eating disorder and self-cutting part of what needed to happen for that patient and she needed to have. Have screening for abuse because that's one of the things that can lead to those behaviors. So just being cognizant of those things is really important. If somebody discloses to you that they have been abused in any context. There are some words that you can use that it can be against supportive non-judgmental communication. So say, you know, thank you for telling me. I know that was something that was really hard to do. If you've ever had to disclose something difficult in any context of your own life, you might imagine how challenging that can be. And so for a team to disclose something to a physician, it can be really powerful or to do a nurses working in the unit. So trying to really practice those communication skills so that if a patient makes a disclosure to us that we're prepared to be supportive. Sexual assault is something that unfortunately many young people are at risk of having happened to them. In particular, girls 16 to 19 are in a particularly high risk category for things like rape and sexual assault. And human trafficking. This is something that is a truly hidden epidemic within our own society. And it happens to children and adolescents in the United States that these patients are sometimes attending school. They are sometimes getting outpatient healthcare. And so being cognizant of that, if things just don't quite seem to add up with your interaction with a patient. So this is something that we should have in our mind. Is this patient a victim of human trafficking? If there are signs that you're concerned that the patient, for example, has been trading sex for resources. If they have housing instability that may have put them at risk. And so taking to human traffickers, pardon me, are increasingly actually taking patients to outpatient healthcare providers. And so again, just being cognizant that these may be patients that you are seeing. So we touched on a lot of issues today. Some of them were challenging than others. But the transition of adolescents from children to becoming adults. And sent in a sent adolescent rights by state. And how complicated they can be depending on where you practice. Communication issues and some special challenging situations that are adolescent patients may face. There's a couple of papers I want to bring your attention to. One of your colleagues, Robert Holtsman wrote a lovely review on perioperative care of adolescents. But if you haven't seen it, I highly recommend it. And this is a paper that I wrote with a few of your colleagues, Dr. Robert Trug, as well as Tom and Kusso. So this is a paper all about a teenager refusing epidural anesthesia for a thoracic procedure. And all of us really just talk about the different ways to think about that case from an ethics perspective. There's a number of resources that are out there. If you're interested in learning more about adolescent rights, you're interested in learning more about adolescent care. The American Academy of Pediatrics has a number of resources that are particularly helpful. You have an entire committee dedicated to adolescents. And there's other resource centers as well. I appreciate all of your time. I know it's it's early for me and it was early for you. And so thank you all for being here this morning. Thank you so much, Alyssa. That was a really fantastic talk. Are there any questions or comments from anyone feel free to just chime in or enter them in the chat box? Laura, this is Mary. I do have a question or comment, I should say. Hi, it's Mary Landigan. Alyssa, thank you for a fantastic talk. I just wanted to sort of pick up on one thing that you said. You know, it sometimes seems like we in the parioperative environment aren't going to really have an impact on child's mental health care, for example. And just as a counter example to that very recently, we had a child show up for an appendicitis who happens to screen positive person silo ideation in the emergency room. This is the kid who had recently changed living from their mom to their dad. And you know, it could definitely have been in danger of some unmet mental health care needs. And because they showed up for emergency operation, we were able to help them with getting access to mental health services in their new house. So don't discount the role that we can play in the parioperative environment and helping these kids. Absolutely. Mary, thank you so much for sharing that story because it's true. And these are exactly the kinds of experiences we're having as well as that sometimes there's this sense of, oh, well, I don't know what I'm going to do about that because it's the morning of surgery. We have like, we got to keep things moving, but that as an adult person who is a health care provider, you truly can make a difference in the lives of these patients. And even if it means just connecting them to the resources that they need, you may be that entry point. Melissa, hi, this is Bill Sparks. My question for you is if at your home institution, the role, the social worker involved with the parioperative process more and elective and urgent situations. We're saying more than an in elective or emergency. And just saying how how incorporated they are in your parioperative workups. To identifying the community provider and then incorporating any recommendations. Thank you. We I wish we had our own social worker for pariop because we have enough issues that arise in this context. I think that that would be useful. We don't have access to a social worker other than a on call social worker for our first case starts. But for our later case starts and for patients who are hospitalized and certainly we do have access to our social worker. I've also put in social worker referrals for patients who are in new need of a social worker, depending on if that's an outpatient or an inpatient need. I wouldn't say that they're incorporated in the deep and meaningful way that that might be helpful. And part of that I think is balancing the resources that you need in a particular environment. It's a great question. I think you know in the small area, the satellite area where where I help. And I think that if really envelope them. It's part of our parioperative workup. And I'm happy offline to share with you the impact that's had for us in terms of broadening our patient population. That'd be great. Thanks. This is Amy Vincent. I want to thank you for a really outstanding talk. I think when when we incorporated this into the health and wellness lecture series. And I think that the interactions and sticky situations can be really fraught. And a lot of times they're just not dealt with head on because you just don't know what to do. And so I really appreciate the overview and I really appreciate all the skills that you've given us. And it's for the directions to head. And I agree with Bill Fargs where we're very blessed to have a very engaged social worker group. And I think that's a wonderful overview of a very, very big, big topic. Thank you. Amy, thank you so much. And thanks for inviting me. This is really a fun opportunity. And you know, I think the in addition to sometimes us feeling just not not certain of what to say. It's also that some of us were affected by some of these things. In preparing these, it occurred to me that I was absolutely approached by a human trafficker when I was a teenager. It felt like a sticky situation. It felt very uncomfortable and I was thankfully able to get away. And I was like, oh, that was, that was a horrible thing that could have happened to me. And it can, when you've had any sort of adverse childhood experience, these things, they can be triggering for you. And as a health care provider, I think having the ability to look at your own experiences and feel safe and comfortable to help support and adolescent through a difficult time can be, can be really powerful. Let's say I'd like to thank you as well. I just want to make sure that the folks on this zoom and hear your comments. But the last year we put into the place a screening to brief intervention for all adolescents coming through the hospital in the periop area where there is a questionnaire about substance abuse. And then there is a specific sort of algorithm for what gets done depending on the answers to the questions that are given. So we're actually using this essentially as a screening tool. And I don't know if that's something that you all are doing, the private suggestions. That's great. Thanks. Good morning, Joe. We have a screening tool that we use as well in the periop environment. And I think what became clear is because of this year volume of patients that we see through periop, our nurses really said, whoa, there's a real mental health care need within our population and have really driven the conversation at the organizational level. Simply because they're doing so much screening that's really involving us. But absolutely we're also doing routine screening. I think it is hard because we absolutely have a lack of mental health services in our community. There's just not enough for everybody who needs them. All right. I think that looks like it maybe it for this morning. Thank you again. This is so much for for a very informative talk and thank you everyone for joining and listening in it as well. We'll close things out from here. Have a great day. Thanks so much.