Child Abuse Injuries: Part 1/2

I read a lot of fiction. Okay, suspense fiction. What I find missing is an area that seems to be in few books yet inherently has a lot of conflict. Child abuse. What fiction titles are you aware of that, as a central theme, center around child abuse?

April is Child Abuse Awareness Month so I thought I’d do a few posts about child abuse injuries and how medical providers pick up on the fact an injury may be intentional or inflicted.

As a pediatric nurse, I’ve been witness to child homicide at the hands of abuse. Yes, it is murder. It’s a necessary part of my job in dealing with these families, perhaps even the confessed abuser, as I care for the child abuse victim. And yes, there is a lot of conflict in these situations.

How do we as pediatric medical providers begin to suspect that an injury is abusive? During the initial evaluation of an injury, confession among abusers is rare (perhaps, they will confess later.) Often, there is a history given to account for the injury. Both parts: the history of the injury and the injury itself can give red flags for child abuse. Today, let’s examine the story and how it may signal an abusive injury.

The story concerning the injury:

1. Is not realistic considering the child’s developmental level. This is more common than you might think. Most people cannot rattle off when a child should meet certain developmental milestones so they’ll say the child injured themselves in a manner that is beyond their developmental age. For instance, “my daughter broke her arm by rolling off the couch”. The baby is two-weeks old. Infants typically roll over starting at 3 months. Here’s a great resource for any writer/parent for developmental milestones.

2. The story changes. Just like other criminals, abusers can have a hard time keeping their story straight. Often times, the more abusers are questioned about the plausibility of the story, it will begin to change. Medical staff interviewing a potential abuser can be like a detective getting a criminal to confess. The doctor will often approach the caregiver several times to ask questions about the injury to see if the story changes. In later interviews, the doctor may say, “This injury is suggestive of abuse.”

3. The story has too much detail. This one may seem odd but it can be a red flag for abusive injuries. If you have children, think back to their toddler/elementary school years when they seem to come home with lots of bumps, bruises, cuts and scrapes. If asked, could you come up with an explanation for each and every injury? Likely, no. Abusers will try and explain away every injury. A non-abusive parent will be truthful and likely say, “I have no idea how that happened.” and then probably feel guilty about not knowing.

What other parts of a medical history/story might give a signal for abusive injury?

Treatment for Amnesia

Marissa Asks:

How do doctors proceed if they suspect amnesia? In my novel, the patient was brought to emergency after being found on the side of the road (in the snow.) The patient shows signs of physical torture: multiple rapes, bruises, lacerations, glass embedded mainly in his hands, hypothermia, and a cold (because obviously my character needs to be ill on top of everything).

burnout-384086_1920The patient has just woken up and had a panic attack. Been settled down. You asked for his name and he seemed uncertain as he gave his first name. You asked for his last name and the patient shook his head. What next? I mean obviously the glass would have been removed from his hands and a drip put in for painkillers but what next? Who does the nurse call? Or what does she ask now? And if memory loss is confirmed, how do they find out it’s amnesia like which SPECIFIC tests do they do? Who is contacted and brought in to liase?

I just sort of need a timeline rundown because my character is going to be going through that.

Jordyn Says:

Thanks so much for sending me your question. First of all, it sounds like this patient has a period of time where he is unconscious in the ER. You make it sound like he wakes up on his own and not in response to an exam by a doctor.

So an unconscious patient found with these injuries would have a CT scan of his head. Hypothermia could be determined simply by taking the patient’s temperature and warming him up with something as simple as warm blankets to more complex as heated IV fluids. Regarding the IV drip for pain— this is actually unlikely in the ER. This is referred to as a PCA pump (patient controlled analgesia) and I’ve never seen them used in any ER setting. Would we treat the patient’s pain? Yes. But, you might be surprised that we may choose not to use a narcotic (for many reasons) and instead try something like Toradol which is an IV form of an NSAID (which is in the same drug class as Ibuprofen.)

The glass embedded in his hands would be removed. The wounds irrigated and stitched closed if necessary. The lacerations would be treated the same way. Keep in mind, not all lacerations can be stitched closed if they’ve been open too long due to the risk of infection.This patient would also receive a tetanus booster if he hasn’t had one in the last five years (even if he can’t remember the last time he had a shot.) If anything looks infected, he would receive IV antibiotics.

If the patient wakes up and doesn’t know who he is (and doesn’t have any form of identification on him) then we would involve the police. Likely, they are probably already involved considering the circumstances— that he was found unconscious and beaten. Plus, you mention that the character has been raped several times so a sexual assault kit should be collected, but the patient’s consent is required, so we’d ask him if he wants this when he’s awake. Yet another reason the police would be involved.

If the doctors think the amnesia is related to a brain injury from the beating, they may just see if it improves with time.

I think it’s reasonable to admit this patient to the hospital and I speak a lot here about how it is actually rare to admit a patient with concussion, but considering the amnesia (it sounds like you want it to persist), the beating, the rapes, the wounds to his hands (as well as additional lacerations), and the hypothermia then some watchful observation is warranted. The doctors could consider a neurological and/or some type of psychological evaluation considering the circumstances of the case to see if his memory loss has a non-medical cause. Neuro might request an MRI of his brain to look for additional injuries not as easily discerned via CT scan.

In the end, if he never remembers, there’s little treatment to “correct” amnesia. This is good for the writer because you have a lot of leeway in what you want to happen to the character. Your time frame can be what you wish.

I think if he were stable in the hospital for a few days and the neurological/psychological evaluation didn’t warrant anything that required further inpatient treatment, he could be discharged home even if the amnesia persists with outpatient neurological follow-up and perhaps outpatient therapy if he consents.

Obviously the police would be very involved with this case.

Forensic Medical Question: Forensic MRI for Child Abuse

Susan Asks:

mri-782459_1920Is there such a thing as a forensic MRI? Not to be done on a dead person, but in a child abuse case? Can one tell if a child has been beaten and see healed bruises, etc?

Jordyn Says:

Thanks for your questions.

The only indication I can think of using MRI to discern abuse would be for head trauma. MRI is the most sensitive study when it comes to differentiating old and new bleeds (as in possibly discerning two episodes of shaking), but still an exact time of the bleed could probably not be given. We just would know there were two separate instances of injury that caused bleeding.

Also, it wouldn’t be called a forensic MRI on a live child. We would just call it by the study we’re doing. In this case, a brain MRI, but the reason for doing the study would be concern for child abuse and/or intracranial (inside the brain) bleeding.

You can’t really tell healed bruises because they’re healed after all. The skin would have normal appearance. We could at least take a history of where the bruises were because we know normal versus abnormal bruising patterns in children, but pictures are always more impressive so seeing current injuries will always be better if trying to build a child abuse case.

Perhaps you’re thinking about healed fractures which you could possibly see some evidence of healed fractured on x-rays depending on how significant the fracture was. However, not all healed fractures are visible on x-ray. Healing fractures can be seen on x-ray.

How is Blood Type Determined?

There’s nothing more fun as a suspense author then to have a twist in your novel. Some medical twists can be intriguing and one that is in such a category is looking simply at blood type. Knowing a child’s blood type can give you an idea if their parents are really their parents.

b7ab9-bloodbagLet’s say a child has AB blood type, but his parents are both blood type O. I can tell you right now that those parents are not that child’s parents. How? Because you inherit a letter from each of your parents. So this child can be A, B, or AB blood type, but never O.

A parent that is just A or B blood type have an O they can pass on. It might be easier to view them as AO blood type. So if both parents were blood type A— their children could actually just be blood type O from inheriting that “O” from each of their parents. What blood type could they never be?

Type B.

Here is a chart that looks at how blood types are determined. Scroll to the bottom of the page.

As a writer, have you ever used blood type to reveal that a child is not living with his biological parents when he thought he was?

Medical Errors in Manuscripts: Criminal Minds and Bodies Hidden in Cement

Happy Halloween Redwood’s Fans! What fun festivities do you have planned for today? What will your kids be dressing up as to celebrate?

criminalmindsToday, I thought a fitting Halloween post would be an evaluation of a recent episode of Criminal Minds. I’ve been a fan of the show for years and am always intrigued with the cases and devious/suspenseful minds of the screenwriters.

A few episodes back, uber chipperPenelope was presenting a case about a woman who had been buried in a barrel full of cement. She stated the woman’s body was discovered using ultrasound and then proceeded to show a picture of the body that looked like a plain x-ray.

This is a common mistake among writers— not knowing the proper technology to site or the right radiology equipment to use. First of all, ultrasound couldn’t penetrate cement to find the body and the scan images would not resemble anything that you’re used to seeing.

What probably would be used is something that utilizes Ground-Penetrating Radar (something that can actually look through cement) and I found an extensive article that discusses its indications and use which I’ll definitely be referencing later.

Writers— keep in mind that not all forms of radiology are interchangeable with one another. If you’re discussing the use of a particular radiological study in your manuscript— make sure it’s the right one.

Have a safe and happy Halloween!

Forensic Question: Solving Cold Cases


My question is about cold cases. Are you able to test for DNA from blood on a knife or clothes from 30-40 years old? Also, if the remains of a body were found in a mine shaft, could you tell the manner of death from that same time or even older, say, 150 years old? How would you do this and how long would it take? Thanks so much for your help!
Amryn Says:

Cold case investigations have come a long way with the use of DNA technology. Answers that would have been impossible 20 years ago are now commonplace. The problem with cold cases is often in the handling of the evidence. On the knife or clothes that you mentioned, when they were first collected from a crime scene 30-40 years ago, the investigator may not have worn gloves. That seems shocking given what we know now, but it wasn’t all that routine a few decades ago.

What that might mean for your DNA results is that you get a mixture—say, the victim’s blood and another unknown profile. Now, does that profile belong to the killer or just the detective or crime scene tech that handled the evidence without gloves? Without something to compare back to, you won’t be able to say.

Let’s assume best case scenario, though. If the bloody evidence was stored and handled properly, it is definitely possible to get a DNA profile from the blood present on a knife or on clothes. This can usually be done with routine DNA testing, which generally takes 2-3 weeks. Of course, for the purposes of fiction, the DNA could be “rushed” and then results would possibly be available as soon as 48 hours. This testing will probably be done at the police department’s or state’s crime lab.

As far as a body in a mine shaft, unless the body is frozen, it’s likely to be not much more than a skeleton by the time it’s found 30-40 years later, and certainly 150 years. However, if the manner of death was some sort of trauma (i.e. broken neck from a fall or stab wound where the knife grazes the bone), a lot can still be determined from bones.

In most cases, a forensic anthropologist would be the person to make that determination. Some states have one on staff while others call in an expert like Dr. Bass (founder of the Body Farm) when they are needed.  I would say the time frame for that sort of determination is at least a couple weeks, though I’m sure there are cases where it could be done faster. And I should also mention, many forensic anthropologists like to be present when the team is recovering the bones to make sure none are missed and to make observations based on the position of the bones.

**********************************************************************


Amryn Cross is a full-time forensic scientist and author of romantic suspense and mystery novels. Her first novel, Learning to Die, is available on Amazon. The first book in her latest series, loosely based on an updated Sherlock Holmes, is available for pre-order onAmazon. Look for Warzonein January 2015. You can connect with Amryn via her websiteTwitter and Facebook.

Forensic Question: Differentiating Twin Murder Suspects

Sarah asks:
If you have identical twins who are both suspects in a murder, how could you tell them apart?
Amryn says:

Identical twins are a hot topic in forensic DNA. Up until now, it’s been thought that identical twins have identical DNA and therefore are the perfect twist to a murder mystery. We’re finding out now that’s not necessarily true.

Strictly from a DNA perspective, research is showing that even twins have small minute differences in their DNA called SNPs (single nucleotide polymorphisms.) These aren’t routinely tested for in forensics because they’re pretty cutting edge, but such testing could be done (likely by a private lab) if the need arose.
Another option would be generating an antibody profile. When we’re born, we have an antibody profile like our mother. But beginning at birth and until the age of two, our antibody profile is evolving. It’s pretty much set in stone by the age of two and (as far as we know) doesn’t change throughout life. These antibodies are slightly different than the ones you make to fight off disease, but the important part is that they’re unique. Even identical twins will have different antibody profiles. This testing is new and is beginning to be used in conjunction with DNA testing.
Of course, this all depends on what type of evidence is found at a crime scene. Antibody profiling might be useful if some type of body fluid is found (i.e. blood, saliva, tears, sweat, etc.) but not so much with skin cells or hair. And, of course, even identical twins should have different fingerprints, so in a case such as this, DNA evidence might not be as strong as some other possible links.
If you’re interested in learning a bit more about antibody profiling, check out this article: http://www.americanlawyeracademy.com/antibody-profiling-forensic-evidence
************************************************************************
Amryn Cross is a full-time forensic scientist and author of romantic suspense novels. Her first novel, Learning to Die, will be released in September. In her spare time, she enjoys college football, reading, watching movies, and researching her next novel. You can connect with Amryn via her website, Twitter and Facebook.