What to say if you suspect child abuse in the ER

I don’t know anyone that works in health care that does not dread suspected child abuse.

On all levels it is horrible.  Horrible that someone would do such a thing to a child, horrible for the logistical nightmares it can cause in treating the patient, horrible going though the whole mandated reporting process.  It just sucks.  Now, if it is obvious and you are totally sure it’s going on, you do it with a lot more enthusiasm.

Not so if you just have a hunch – or if you find an injury that just seems like a stereotypical abuse pattern even though you really don’t have much suspicion.   In these cases you have to balance all sorts of factors. You have to balance your ethical and legal obligations. You have to consider the logistical aspects of getting the patient treated. You have to consider how the parents are going to react to your actions.  You have to consider what you tell the child protective services workers.

Often it ends badly.  Tons of time on the phone. ER backing up. Meetings with administrators and Child and Protective Services (CPS) personnel.  Arguments with families upset that they think you are accusing them of abusing their child.  Sometimes they attempt to leave and you have to call the police.  Sometimes they try to prevent you from treating the patient since they are so upset at you.  All this is fine when you just know the kid was abused.  But when you are not sure, it is much harder to go through.

So with this in mind, a 2 year old comes in with an injury like this:

This is a spiral fracture of the femur  – an injury that can come just as likely from a toddling child losing his balance and sustaining a twisting fall as it can come from an adult twisting the leg.  The problem in this case is that 5 months ago, the same child came in for a tib/fib fracture of his same leg.  Now we have a pattern.  Two injuries that could be legit but maybe not.  Two times in 5 months is much more suspicious.

However, you interview the family and you don’t get a vibe that the kid’s being abused.  There are no other injuries (old or new) that you can find on your survey.  Your initial suspicions begin to whittle away. Maybe the kid is just a klutz!  But then the father starts to act like an jerk.  Getting irritated things are taking too long.  Pestering the RN’s and secretaries for stupid crap.  Making lots of cell phone calls.  This irritates us and makes me more inclined to think he is guilty. However, maybe he is just an ass?  You wax and wane and finally decide you have to report it.  You go through the task of calling CPS and then they make it even harder!  “So, Doctor, you are accusing this man of child abuse?”  “No, I’m just reporting  something that is suspicious. That’s for you to figure out.”

Luckily in this case the parents understood that it was suspicious and did not raise a huge fuss about us having to report it. The kid got his leg fixed by ortho.  Hopefully the CPS people will get to the bottom of it one way or the other and the kid will be ok in the future.

“ER Stories” is an emergency physician who blogs at his self-titled site, ER Stories.

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