Medical Critique Hostages: One Episode to be Thankful For

Okay, I admit it. I’ve been beating up on the CBS drama Hostages. So– since it is Thanksgiving and we’re to be thankful I’m going to give a shout out to Hostages for one accurate story line.

Then it will be back to a hard medical critique as there is MUCH to discuss in some of the most recent episodes.

In one of the minor plots, the teen daughter is, of course, pregnant. Her father takes her to an OB/GYN to check the status of the pregnancy and stays in the waiting room.

Accurate portrayal #1: Teens presenting for care related to reproductive issues or sexually transmitted diseases are treated as adults in the sense that they don’t have to have a parent present to consent for treatment and should be seen privately by the physician.

During the exam, the physician asks her what all the bruising is about. And, the teen girl does have a suspicious bruising pattern.

Accurate portrayal #2: Suspicious bruising patterns are those that:
1. Can’t be explained by the history given (I fell down the stairs.)
2. Are located over non-bony prominences. This teen presented with bruising to her upper arm (from being grabbed) and to her back (from cutting out a tracking device.)
3. Are numerous and extensive.

The doctor becomes suspicious and notifies social services.

Accurate portrayal #3: A physician is a mandated reporter under most state statutes to report a suspicion of abuse. They don’t have to know beyond a shadow of a doubt that something is happening but if, in good faith, they are concerned by what they see then a report is necessary.

In a few days the teen is approached at school by a county social worker for questioning.This occurs in episode seven.

Accurate portrayal #4: There would definitely be an evaluation of the teen in private– away from the parents. The social worker also interviewed the brother, who also had a black eye. Alone. In psychiatric situations involving teens the family is generally interviewed together and at some point– each member is interviewed alone to get what’s really going on.

So on this Thanksgiving Day– thank you Hostages for accurately portraying management of a family when there is concern for abuse.

Now everyone– have a safe and great holiday. I’ll be working the ER and I don’t want to see you ;)!!

Plausible Deniability: Child Abuse

Unfortunately, as a pediatric ER nurse, it is part of my job to deal with abhorrent parts of family life. The parts that the average citizen doesn’t think about on a daily basis. Maybe even they deny what is in front of their very eyes.
What I know to be true is that children are abused. Their most likely abusers are those closest to them. Mothers. Fathers. Boyfriends. Caregivers. It is not the stranger on the street that comes in, shakes your infant, and then disappears into the night.
When I began working in the pediatric ICU (PICU) what surprised me most was not that children were abused but that the general public didn’t believe it and it was very hard to get people convicted on child abuse charges for just that reason. It wasn’t that there wasn’t sufficient evidence . . .  it was that the jury simply couldn’t believe that a mother, any mother, would willfully press her child’s hand to an iron and hold it there.
Surely, that was accidental.
Maybe you have suspicion that a child you know is possibly being abused but you’re afraid to take that step of contacting someone in a position to help. You may say to yourself– I don’t really know what the signs of child abuse are– and I don’t want to put anyone through needless accusation.
So, what are some of the classic signs of child abuse? I’ll list some here. Remember, one of these symptoms in isolation doesn’t always indicate abuse (thought it also may) but the more items on this list that you see– the more likely is the possibility the child may be being injured. I’m going to focus on physical abuse.
1. Bruises over non-bony prominences. Common childhood bruising occurs to the knees, shins, elbows, and forehead. These tend to be the areas that children fall onto. Bruising to the buttocks, abdomen, back would be areas that are not bony prominences. Now, one bruise to the buttocks may not be indicative but multiple bruises to the buttocks– particularly in a diapered child– is concerning.
2. The bruise has a shape/pattern to it. Think about all the bruises you’ve seen on a child. They are typically round, irregularly shaped– and over a bony prominence. Bruises with a pattern are often inflicted. It takes force to imprint the pattern onto the skin. Think of a bullet. There is much more damage inflicted on a person if I fire it from a gun versus if I just hold it between my fingers and tap you with it.
3. The history does not match the injury. Think about what a child should be able to do normally. Say you have a neighbor with a two-week-old baby who always is bruised up. She says the baby just keeps rolling off the couch. One, a child of that age cannot do that developmentally. This should be red flag #1. Also, any bruising to the face, head, and neck of a child who is not yet pulling up to stand is concerning because– how are they hurting themselves if they aren’t falling down?
So, take some of these things into consideration when you are concerned about a child who may be being abused. Most of all, if you’re gut is telling you something is wrong– listen to it. You may be the only adult who will stand up for that victim and actually save a life.

Child Abuse Injuries: Shaken Baby Syndrome 3/3

April is Child Abuse Prevention month and as a pediatric ER nurse, I thought I’d spend some time talking about the most devastating child abuse injury, in my opinion, and that is Shaken Baby Syndrome or SBS.
In Part I and Part II I talked about the brain injuries associated with SBS: Diffuse Axonal Injury and Subdural Hematomas.
Now—we’ll discuss another classic injury associated with this abusive injury—retinal hemorrhages.
Just what is this bird? Anyone know? Well, it is a woodpecker. Now you may be wondering exactly what do woodpeckers have to do with shaken baby injuries.
Interestingly, Alex Levin, an ophthalmologist from Canada, wondered why woodpeckers did not suffer retinal hemorrhages when they were pounding their beaks against trees. After all, the whiplash type movement is similar to the injury infants suffer when shaken.
So he got a grant and if you found a deceased woodpecker, you could send it in for money and he sent these birds through the CT scanner.
What he found was that anatomically, woodpeckers had certain mechanisms built in that protected their eyes from sustaining injury.
We know that when an infant is shaken—the brain is tossed around within the skull causing injury. Essentially, the same thing happens to the eyes—they are tossed around as well and hit their bony protective area—the orbits. Imagine a tethered ball hit and tossed around. This mimics the eye anchored by the optic nerve and how it is injured during shaking.
The retina has several layers and bleeding happens in between these layers. Retinal hemorrhages associated with SBS are extensive, in both eyes, and cannot be mimicked by any other type of injury—including a violent car accident. 
What people who perpetrate child abuse don’t understand is that the injuries associated with SBS are VERY distinctive. Multiple studies (particularly of falls) have been done and we know that no other injury pattern (major car accident, falls less than four feet and CPR) gives us this cascade of injures.
What’s distressing is getting the public to believe that parents perpetrate these crimes. Surely, no loving parent could cause this type of injury that led to their child’s death.
Sadly, yes they do. Every day.
Please—if you think a child is being injured. It may be you—and only you—who ever stands in the gap to save their life. Please notify someone if you think a child is being abused. 

And please– never, ever shake an infant. 

For help in dealing with a crying baby– click here

Child Abuse Injuries: Shaken Baby Syndrome 2/3

April is Child Abuse Prevention month and this week I’m posting about the most devastating child abuse injury—Shaken Baby Syndrome or SBS.
Last post I discussed the leading cause of death is a brain injury called Diffuse Axonal Injury (DAI) which leads to massive swelling in the brain, which if not controlled will push the brainstem into the spinal cord, and this leads to brain death.
There are other classic injuries associated with SBS. In Part I I described how DAI occurs—by the violent shaking and the brain hitting the inner surface of the skull repeatedly.
What also occurs is the small bridging veins that cover the brain and are attached to the underside of the skull are torn as well. This leads to bleeding on the brain and is referred to as a Subdural Hematoma (SH) or subdural bleed. This can be picked up radiologically and although forensically a specific time and date cannot be given as to when the bleeding occurred—a radiologist can tell if there are old and new bleeds which correlates to different episodes of shaking.
People who have committed this type of child abuse injury have confessed to shaking multiple times. It’s as if they see shaking work one time to quiet an infant’s crying—it’s an easy solution the next time.
As stated in the earlier post—the bleeding is generally not what kills the child—it is the insidious brain swelling and subsequent herniation.
How do these children present to medical personnel?
Mild Presentation:

Large head.
Can’t lift their head.
Eyes can’t focus or track.
Decreased Responsiveness.
Decreased muscle tone.
Poor appetite.
Not smiling.
Not vocalizing.

Severe Presentation:
Decreased respiratory rate.
Not breathing.
Rigid posture.
Bulging soft spot.
The medical team is generally clued in to the possibility of child abuse when a caregiver gives an implausible account of why the child is so sick. Typical responses are—“Well, my one-month-old baby just rolled off the couch.”
Hmmm… if only he could roll.
Next post we’ll talk about another classic injury associated with SBS.

And please– never, ever shake an infant. 

For help in dealing with a crying baby– click here

Child Abuse Injuries: Shaken Baby Syndrome 1/3

As a pediatric ER nurse, I would be remiss in not taking note that April is Child Abuse Prevention month. Sadly, this is part of my job as a pediatric ER nurse—to recognize and report child abuse injures.
A couple of years ago, I did a two part series on how we identify child abuse injuries. You can read Part I and Part II by following the links.
This week I thought I’d highlight one very specific injury—Shaken Baby Syndrome (SBS).
In the medical community, SBS goes by another name—abusive head trauma (AHT) and many things can fall under this designation. A child who is just shaken, a child that is shaken and then slammed into a surface, or a child who is beat about the head.
Fatal child abuse can occur from a single act (drowning, suffocating, shaking), repeated abuse (battered child syndrome), or failure to act (malnourishment or bathtub drowning.) Eighty percent of perpetrators are generally the biological parent(s) followed by mother’s paramour and babysitters.
SBS is caused when a person generally grabs an infant around their torso and shakes them violently in order to quiet their crying. We don’t know exactly how long it takes and no sane ethical review panel is going to allow infants to be shaken to unconsciousness to find out. What we know from people who have confessed is that it doesn’t take very long—likely twenty seconds or less—typically lasting five to ten seconds.
Imagine holding a ten to twenty pound baby with outstretched arms and sustaining that position. The shaking is violent and requires a lot of energy as well. 
What happens upon shaking is as follows:
1.      The brain strikes the inner surfaces of the skull, causing direct trauma to the brain itself. This is often referred to a coup/contra-coup injury. The brain is injured both ways as it is batted around within the skull.
2.      The axons, which are the long part of the nerve cell (you can view them like an electrical wire) can be broken or sheared. Whenever there is biological injury things swell (like your ankle when it is badly sprained.) This occurs to the brain as well. This is referred to as Diffuse Axonal Injury or DAI.
3.      The lack of oxygen during shaking causes further irreversible damage to the brain. This is referred to as Anoxic Brain Injury.
4.      Damaged nerve cells release chemical mediators which further damage cells.
5.      The end result is brain swelling, brain movement (herniation) and brain death.
There are other injuries that are classically associated with SBS but the diffuse axonal injury and subsequent brain swelling are generally what cause death.
Why is this different than brain injuries from a car accident? Why can’t kids recover?
Think of a car accident. It may entail one or two hits—a focal injury. A focal injury means just one area of the brain may be injured. Given time, the brain may rewire itself pretty amazingly in this age group and they tend to do better than those suffering from SBS.
Sadly, the whole brain is injured in SBS and therefore there is no healthy brain tissue to attempt recovery. Due to pressure and swelling within the skull, the brainstem is forced into the spinal column (herniation) which disrupts blood flow to it. This is the area that control heart rate and respiration.
Next post we’ll talk about other associated injuries. 

And please– never, ever shake an infant. 

For help in dealing with a crying baby– click here

Forensic Issues: Bruising

On every crime show where a murder has occurred, there’s usually a big scene with the medical examiner asserting time of death or determining the time of an injury. In pediatrics, this becomes important when we look at timing a child abuse injury so we can place who was with the child during the suspected event.

The question is, can bruising give an exact time for the injury?

 Bruising happens when an object comes into contact with the skin, and the small capillaries underneath break open and cause bleeding. Generally, patterned shaped bruises are more suspicious for intentional injury. For something to make a pattern on the skin, it generally needs speed or velocity to imprint the pattern onto the skin. For instance, it is far different if I tap you with a belt versus swinging and slapping it down.

Point blank, bruising is not a good way to determine time of injury. Bruising is influenced a lot by the individual person. Are they on blood thinners? Do they normally heal quickly? Age factors influence speed of healing as well. Bruising can give a time frame but color of bruising is also open to interpretation. Here’s one set of guidelines.

Color of Bruise
Red– swollen/tender: 0-2 days
Blue/Purple: 2-5 days
Green: 5-7 days
Yellow 7-10 days
Brown 10-14 days

As you can see, 48 hours is a large time frame. In the case of pediatrics, imagine the potential of how many people could have come into contact with an infant.

Interesting bruising fact: Bruises generally heal from the inside out. If you watch a bruise you have, you’ll notice they become lighter at the center as healing progresses.

Did you think bruises could give an accurate time frame for injury?