Child abuse is not always obvious to the caregiver and can unfortunately go undetected to the detriment of the child. I learned this early on in my training. I was a first-year resident at General Medical Center and was on tour in the hospital’s pediatric unit with Peggy, the unit charge nurse. As we walked down the corridor I noticed a young child in room 106 in a full leg cast, which had been placed in traction. I asked Peggy what had happened to the patient. Peggy said, “Oh that’s Gracie. Poor thing. She broke her femur tripping over a toy in her home.” I thought to myself that was a major injury for tripping over a toy. I questioned Peggy further and she told me that she knew where I was leading by my questions and said, “Oh you can be assured that Gracie had not been abused. She has the sweetest mother and father. Although they are divorced one of her parents is here everyday. I even questioned the mother and she assures me it was an accident.”
I had an uneasy feeling about the mother’s story and decided to visit the radiology department to review Gracie’s X-rays with the radiologist on duty. I walked into the imaging reading room where I found three radiologists reviewing various imaging studies. I introduced myself as a first-year resident to Dr. Patrick Williams, the medical director of radiology. I asked Dr. Williams, “Do you have time to review Gracie’s X-rays with me.” The radiologist replied, “No problem. What is Gracie’s last name.” I told him and he pulled up Gracie’s X-rays electronically on a computer screen. As soon as he pulled up the X-rays he said, “Oh yes, Gracie has a compound fracture of the femur.” He was very patient as he thoroughly reviewed with me Gracie’s case. He pointed out the compound fracture of the femur with the computer cursor. I asked him, “Do you think the injury could have occurred from Gracie tripping over a toy at home on a plush carpet.” He replied, “That would be highly unlikely.” He called over one of his partners and said, “Does this patient’s injury look like she tripped over a toy.” Looking at me he said, “Is this what you were told you?” I said, “Well, yes, I was.” He looked at me and said, “I have been reading imaging studies for over 20 years. It is highly unlikely that Gracie’s compound fracture of her left femur is the result of her tripping over a toy.” The third radiologist in the room commented, “Definitely not caused by a slip on a toy.”
Following my review with the radiologists, I called Peggy and asked if she had time to review Gracie’s medical record with me after lunch. Peggy replied, “Sure thing, I will see you after lunch.”
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After lunch I went to the pediatric unit. Upon arriving on the unit Peggy and Caroline, a hospital social service worker, greeted me. Caroline said, “I contacted child welfare in the county in which Gracie resides. They informed me that Gracie was an active child abuse case, which they have been following for the past 6 months. They thanked me for the information and will be in the hospital late this afternoon to follow up.”
Answer the following questions:
- Discuss what lessons the caregiver can learn from the resident’s observations and persistence in learning more about the cause of Gracie’s injury.
- Assume you are the hospital’s director of inservice education, explain what steps you might take to reeducate staff as how to identify and report suspicions of child abuse.