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Case 1: Dispatch advises a two-month-old "stopped breathing." The baby's father meets you at the door, holding the baby. As you begin your assessment/ATLS protocol, your partner notes the surroundings: the TV is on, and empty beer bottles are strewn on the table. The father informs you that the mother is at work. His breath smells like alcohol. The baby is in full arrest, and Dad states, "He's been so fussy all day."
Case 2: Dispatch calls in a 10-year-old male with a broken arm. The mother lets you into the house, where you find the boy lying on a couch, crying. Although he is trying to be stoic, he is unable to move without assistance. His back is covered with bruises. His mother stands beside the patient, with a flat affect. The boy tells you his father had disciplined him because he "didn't practice the piano." He points to the 2" x 4" board in the corner of the room. The EMS provider sees blood on the carpet next to the couch, and the patient tells you his father has left the house.
Because EMS providers are often called to homes with children, they can have an important role in identifying and documenting vital information that could provide evidence of child abuse. In the first case, the EMS crew is driven by the severity of the scenario—the child is in full arrest. The medics astutely picked up on important "at-the-scene" details that would aid in the differential diagnosis and timetable of events. In the second case, important information collected includes the mother's flat affect and the child's appearance and statements.
Both of the above cases are presentations of child abuse. During every emergency call, prehospital providers must attune their senses to identify their surroundings and accurately describe the environment to which they respond.
Documentation
Proper documentation of all information collected is of utmost importance. Often, cases of abuse involve life-threatening conditions that need prompt and efficient response to resuscitate, pack and transport the patient. Awareness of surroundings, observation of other children in the home and history provided by the caregiver must be documented accurately. It is imperative to use clear, objective language in documentation, avoiding your own judgment, no matter how horrific the abuse may be.
Document in your secondary survey any bruising, swelling or other external injuries. This will aid in quicker diagnoses when the patient is brought to the emergency department. Document presence of blood excretions, including vomit, that may be around the patient at the time of your intervention. Take note of and document mechanism of injury. Note the area in which a caregiver says the patient sustained a reported fall or impact. Mentally note and estimate heights of chairs, couches or beds from which a caregiver states the patient fell. Did the patient fall on carpet, hardwood or tile flooring? Record the statements of any bystanders. Is the history provided consistent? What emotions are displayed by the caregiver? Remember, your contact with the initial scene must be documented, as it preserves in writing details that the crime scene investigators may not see later on.
Special-Needs Children
It is important that prehospital providers have an understanding and awareness of special-needs children, as statistics show that these children are at high risk for abuse and neglect. Observe and document surroundings, hygiene and location of the patient. As with all patients, document the caregiver's history and his or her interaction with the patient. Unfortunately, very caring caregivers can be wrongly accused of abuse. Careful listening, observation and objective documentation are crucial, in addition to the critical care given these fragile children.
Cultural Awareness
Be aware of cultural values and practices within the neighborhoods to which you respond. Without this knowledge, a provider bias may emerge. Be aware of differentiating folk practices that may mimic abuse. When called to a scene, identify an appropriate translator, be it a relative or child. As with any other case, the emphasis is to observe, assess, document and transfer the patient to the emergency department.
Reporting Abuse
Child abuse and neglect cases are horrifying and emotionally challenging. Remember, never confront a caregiver with your suspicions. Your primary role is to treat, stabilize and transfer the patient safely and efficiently. Confrontations will only interfere and may be dangerous. In Georgia, prehospital providers are mandated reporters, and suspected child abuse is reported to the Department of Child and Family Services (DFCS) agency in the county in which the abuse occurred. EMS must also report suspected abuse to ED personnel when delivering the patient. Reporting your concerns to relevant agencies in the involved county will ensure that your concerns reach the appropriate authorities. You may be providing the only vital piece of information from the scene necessary to the investigation.
Conclusion
As prehospital providers, you must remember the impact you have on abused and neglected children. Working with the hospital, as well as child protective services and centers, intervention and help for the patient and families will be pursued, preventing further harm to the child.
Terese DeGrandi, MD, served as a pediatric emergency medicine physician at Children's Healthcare of Atlanta from 1985–2000. She was the Medical Director of the Child Protection Center from1992–2006, and has been involved in training healthcare providers regarding child abuse throughout the state of Georgia.
author: By Terese DeGrandi, MD