Child Trauma & Fatality CasesWhat Role Do Medical Professionals Play?Dr. Kenneth McCann, DOMedical Director, Regional Child Protection CenterBlank ChildrenChildren‘ss Hospital
Medical Providers
Overview IdentificationMandatory ReportingConsultation(( Medical Examiner))TreatmentPrevention
Identification Child abuse is a disease Diagnosed just like other diseases: History Physical Examination
Common Things Are Common
Neglecting Neglect Most common cause of death from child maltreatment Worse Outcomes than CPA/CSA PsychosocialCognitive DevelopmentEmotional DevelopmentAttachment DisordersJuvenile DelinquencyAdult Criminal BehaviorDifficulties parenting in future
History Risk FactorsFactors* No historyIncompatible historySignificantly changing historyChild not developmentally capable of a stated action 5‐month‐old “climbed out of the crib and fell” Delay in seeking care All the above in the context of the families culture andsocioeconomic circumstances.
History Important questions? What was the child wearing? Whath happenedhd afterf theh injury? Who else was there? If an accidental injury,injury consider possible supervisionalneglect. (Most common cause of death from child maltreatment)
Physical Examination Plot heightg and weightg Most malnourished kids don’t look malnourished Neurologic exam* Check everyy inch of skin Absence of bruisesAbsence of injury Look in the mouth Palpate/movep /extremities* Squish on the belly (bruising)* * Babies can, and will, fool you!!
Skin Findings Bruises: Active kids bruise “Those“ hthath don’td ’ cruise, rarelyl bruise.”b” Burns:Patterned burns/Cigarette burnsWell demarcated/symmetricyburns“Glove and stocking” burns
Highly Concerning Fractures Metaphyseal fractures (Corner/Bucket handle)S iSpinousprocess fracturesf(Vertebral)(b l)Scapular fractures (Shoulder blade)Sternal fractures (Chest bone)Posterior rib fracturesAlso,, anyy typeyp of fracture in a non‐ambulatoryy child should be ofconcern (i.e. 12 months)
Abusive Head Trauma(Shaken Baby Syndrome) VERY general overview Trauma to Brain/Spine/Eyes from an inflicted event Shakingg and/or Impact Violent May have associated fractures
Abusive Head Trauma(Shaken Baby Syndrome) Challenging diagnosis Variable degree of symptoms Undependable caretaker history Many cases or missed or misdiagnosed High index of suspicion Shaken baby syndrome is NOT a controversy
Mandatory Reporting
Reporting of Abuse/Neglect“Mandatory reports” include helping professionals in the followinggenerall categories,ti as definedd fi d ini IowaICodeC d Health Mental health Education Child care Law enforcement Social workTo report a suspected case of child abuse: Call 1‐800‐362‐2178. Then, follow up by making a written report within 24 hours.
Mandatory Reporting Must report a suspicion of abuse.abuse Reporters don’t have to validate abuse or have proof. Reportingpg a suspicionpof abuse is not an accusation.
Assessment ProcessAs a medical professional how may I be asked to assist in achild abuse/neglect assessment? As a collateral contact for the DHS assessment worker toobtain information about the child’s medical history. As a professional consultant Child Protectionoo Centers/Child/Advocacyo y Centers As a participant in any judicial proceeding resulting from thereport or relating to the subject matter of the report.
What about HIPAA?!?Waiver of Confidentiality Rules around confidentiality and privileged communication arewaived during the child abuse assessment process (once a reportof child abuse becomes a case). IowaIC d sectionCodeti 232.71BB iindicatesdi t ththatt ththe DDepartmenttt mayrequest information from any person believed to have knowledgeof a child abuse case. County attorneys, law enforcement officers,sociali l servicesiagencies,i andd allll mandatorydreporters (whether( h h ornot they made the report of suspected abuse) are obligated tocooperate and assist with the child abuse assessment upon therequest of the Department.
Medical Examiners
What is a Forensic Pathologist? A medical doctor who has completed training in anatomicalpathologyh landd sub‐specializedbi li d ini forensicfi pathology.h l Performs autopsies/postmortem examinations to determinethe “cause of death”. The autopsyp y reportp contains anopinion about: The pathologic process, injury, or disease that directly results inor initiates a series of events that lead to a pperson's death,, alsoknown as “mechanism of death” (i.e. exsanguination caused bya stab wound). The “manner of death",, the circumstances surroundingg thecause of death (i.e. homicide).
Forensic Pathologists can also assist by: Collecting trace evidence.Determining the identity of the deceasedExamining and documenting wounds and injuries.Collecting and examining tissue specimens under themicroscope.microscope Collecting and interpreting toxicological analyses on body tissuesand fluids. Working closely with the medico‐legal authority concerned withthe investigation of sudden and unexpected deaths.g as an expertp witness in civil or criminal law cases. Serving
Iowa Office of the State Medical ExaminerState Medical Examiner: Julia Goodin,Goodin M.D.MD Deputy State Medical Examiner: Dennis Klein, M.D. Associate State Medical Examiners: Jonathan Thompson, M.D.,Michele Catellier, M.D. State Medical Examiner InvestigatorsCounty Medical Examiners: 99 Counties County Medical Examiner Investigators
Iowa Law and PolicyIowa Code § 331.802 states:“A person's death which affects thepublic interest as specified insubsection 3 shall be reported to thecounty medical examiner or the statemedical examiner by the physician inattendance, any law enforcementofficer having knowledge of thedeath the embalmer,death,embalmer or any otherperson present. The appropriatemedical examiner shall notify the cityor state law enforcement agency orsheriff and take charge of the body.”
What constitutes a death of “public interest”: Violent death, including homicidal, suicidal, or accidental death. Death related to disease thought to be virulent or contagiouswhich may constitute a public hazard. Death that has occurred unexpectedly or from an unexplainedcause. DeathD th off a person ini statet t care (correctional(til facilities,f iliti mentalt lhealth institutes, juvenile home, state training school, etc.) Death of a person if the identity of the deceased is unknown. Death of a child under the age of two years if death results froman unknown cause or if the circumstances surrounding thedeath indicate that sudden infant death syndrome may be thecause of death.
The county medical examiner shall conduct theinvestigation in the manner required by the state medicalexaminer and shall determine whether the public interestrequires an autopsy or other special investigation.In the case of a death of a child under two years (asdescribed in previous section), Iowa law requires that thecounty medical examiner order an autopsy.
Child Death Investigations Thorough scene investigation withdoll reenactment Thorough history with interview of allcaregivers/witnesses Recent and remote family and socialhistory Detailed account of activities andencounters of previous hours and days Complete access to entire medicalhistory of child/infant including birthandd prenatalt l recordsdSource: Michele J. Catellier, M.D., Associate State Medical Examiner, State of Iowa
After death,death the body should not be altered prior to autopsy Leave emergency medical devices in place Do not clean the body Do not change clothing, diaper, etc. If clothing is removed during resuscitation, send it with thebody Consider bagging the hands in paper bags (i.e., if physicalaltercation).altercation)Source: Michele J. Catellier, M.D., Associate State Medical Examiner, State of Iowa
Limitations of AutopsyWhat can’t we do? Hematologic studies Coagulation Electrolytes Arterial blood gas (ABG) Temperature assessmentBruises CANNOT be agedTime of death CANNOT be scientifically determinedExternal injury (or lack thereof) does NOT accurately predictinternal injury Asphyxia– Particularly difficultSource: Michele J. Catellier, M.D., Associate State Medical Examiner, State of Iowa
Manners of AsphyxiaStrangulation Ligature Manual HangingDrowninggEnvironmental i.e. refrigeratorSource: Michele J. Catellier, M.D., Associate State Medical Examiner, State of Iowa
Smothering: obstruction of airway Plastic bagsg Poke‐ballsChoking Hot dog, hard candy, latex balloon
Traumatic Overturned furnitureTraumatic/positional Defective cribCombination traumatic asphyxia andsmothering Overlay BurkingSuffocating gases: displacement ofoxygenSource: Michele J. Catellier, M.D., Associate State Medical Examiner, State of Iowa
Sudden Unexplained Infant DeathSince the mid‐latemid late 1990s medical examiners andcoroners have moved away from classifying many infantdeaths as SIDS and are calling more deaths accidentalsuffocation, asphyxia, or unknown cause.91 deathsd th off infantsi f t ( 12( 12 months)th ) ini Iowa,Ioccurringi gfrom 2008‐2009, were reviewed by the Child DeathReview Team as “sleep‐related deaths” to determinepresence of risk factors for SIDS/SUID.
Sleep Related Deaths in Iowa The most common sleep surfaces involved were adult beds and couches. Soft bedding was a significant factor in 65 of the 91 total deaths. In 34 deaths, the infant was placed to sleep in the prone position and in48 of the total cases, the infant was found deceased in the proneposition. In 40 of the 91 infant deaths, co‐sleeping with one or more adults or olderchildren was a contributing factor in the deaths. 53 infants were exposed to tobacco products and 45 infants wereexposed to alcohol or illicit drugs either in utero, environmentally or theircaretakers at the time of death were under the influence or thesesubstances.
Death Investigations MUST beInterdisciplinaryThe autopsy involves a complete HISTORY andPHYSICAL examination.A cause of death is not necessarilyy THE cause of death!
Every Death Investigation Has a SceneHow would the investigation at the timeof death differ if the end results wereknown initially?Team members must anticipate surprises!It may be days or weeks before it isknown that
Potential Surprises Surprises The childchild’ss toxicology is positive The cultures and histology fail to demonstrateinflammation/infection The chemistry shows evidence of an allergic reaction The battery of tests fails to demonstrate a cause of death The intracranial hemorrhage and eye findings are found tobe consistent with inflicted injury
Prevention
CDRT sub‐committee concluded that a majority of infantsleep‐relatedpdeaths in Iowa included identifiable risk factorsin the baby’s sleep environment that research suggestsincreases an infant’s risk of SIDS/SUID.Therefore many of these deaths may have been completelyTherefore,PREVENTABLE!
Preventing SuffocationRecommend safe sleepingp gppractices,, such as: Place infants on their backs to sleep Use a firm mattress that meets currently mandated safetystandardst d d Remove quilts, loose bedding, stuffed toys, and other softobjects from crib Keep infant’s head uncovered Do not allow infant to share a bed with adults or other children DoD nott allowlliinfantf t tto sleeplwithith adultsd lt on a sofaf or reclinerli
Safe Sleep
Prevention
Crying Anticipatory Guidance Provide information on normal cryingIncreased crying begins 2 weeks of ageCrying peaks during the second monthy g decreases between third and fifth monthsCrying
Period of Purple Crying P Peak of CryingP‐PeakU‐UnexpectedR‐Resists SoothingP P i LikeP‐PainLik FaceFL‐Long LastingE‐Evening Parents receive DVD at birth hospital Follow up with primary care
When to Talk Prevention?Anytime is a good time!!! Healthcare pproviders should take everyy opportunityppy todiscuss prevention with caregivers: Prenatal appointments At hospitalhit l (labor/delivery)(l b /d li) Family/Pediatric care clinics Well child exams Urgent care clinics Emergency departments Alsol consider new technologiesh lto reachh parents andcaregivers, i.e. blogs, apps, social media, etc.
Ongoing Treatment NeedsHealthcare professionals may also play a role in treatment forchildren who has been victims of child abuse and/or neglect by: Providing follow‐up care Failure to thrive Making additional referrals MentalM t lhhealth,lth substanceb tabuse,betc.t Trauma informed care Serving the unique needs of children in the foster care system
ConclusionDr. RoeslerDrRoesler’ss Rules for Child Abuse:1. Identify it2. Stopp it3. Provide for children’s ongoing safety4. Repair whatever damage is possible5. Do above with least intrusiveness to the family
THANK YOU!!
(Shaken Baby Syndrome) VERY general overview Trauma to Brain/Spine/Eyes from an inflicted event Shaking and/or Impact Violent May have associated fractures. Abusive Head Trauma (Shaken Baby Syndrome) . doll
6 Definitions of police reported casualty types: Casualty Crash - crash where at least one fatality, serious injury or minor injury occurs. Casualty - A fatality, serious injury or minor injury. Fatal Crash - A crash for which there is at least one fatality. Fatality - A person who dies within 30 days of a crash as a result of injuries sustained in that crash.
Behind the Term: Trauma Prepared in 2016 by Development Services Group, Inc., under contract no. HHSS 2832 0120 0037i/HHSS 2834 2002T, ref. no. 283– 12–3702. 1 Behind the Term: Trauma Related terms: complex trauma, historical trauma, human-caused trauma, naturally caused trauma, trauma,
categories of trauma as a framework for trauma assessment. “Little t” trauma “Big T” trauma Complex trauma “Little t” Trauma “Little t” trauma involves events that we encounter day to day that can make life difficult but are not out of the ord
The assessed content included prima - ry survey, secondary survey, airway and ventilation, circulation, shock, thoracic trauma, head/spinal trauma, abdomen/pelvis trauma, musculoskeletal trauma, paediatric trauma, geriatric trauma, obstetric trauma, trans - fer of care, and other course specific inclusions.
LEVEL I PEDIATRIC TRAUMA CENTER The Level I Regional Pediatric Trauma and Burn Center at Children’s Hospital Colorado is a large, multi-disciplinary program. We provide timely, comprehensive, cost- . Trauma/Burn Medical Director Trauma/Burn Program Manager Trauma Coordinators Trauma Registrars Staff Assi
Historical trauma - Cumulative emotional and psychological wounding from massive group trauma across generations, including lifespan Historical trauma response (HTR) is a constellation of features in reaction to massive group trauma, includes . historical unresolved grief (similar to Child of Survivors Complex re: Jewish Holocaust survivors and
The Georgia Action Plan for Child Injury Prevention is developed by the Child Injury Prevention Plan Workgroup, and supported and monitored by the Georgia Child Fatality Review Panel. Georgia Child Fatality Review Panel Chair . For Researchers and University Partners For more than four decades, the scientific study of childhood injuries has .
Care needed: (check all that apply) Child #1 Child #2 Child #3 Child #4 Child #5 Preferred Location (Zip Code other than home) Full day Part day Evenings Overnight Weekends Special Needs: Child #1 Child #2 Child #3 Child #4 Child #5 Limited English Child Protective Services Severely Handicapped