Recently, I overheard a colleague lamenting the poor social support of some of our patients. It reminded me of a crisis I encountered some time ago, when I suspected one of my patients was a victim of child abuse. At the time, I had no idea what action to take.
The patient was a young boy who presented for a procedure at an outpatient surgery center. He was poorly dressed and small for his age. He appeared developmentally delayed, having the speech and behavioral patterns of a younger child. His very presence at the center categorized him as a child at risk; the typical pediatric patient in that population lives below the poverty line in a household with unstable and complex relationships. Although child abuse occurs in all socioeconomic levels, financial stress, inadequate housing, lower parental education, and disabilities are risk factors for child maltreatment.1
The patient's parents accompanied him and were able to provide his medical history, which was unremarkable. However, they added that the patient's sibling once had a reaction to anesthesia and subsequently developed cold sores. I noted this unusual detail and proceeded with the anesthetic as planned.
After the patient underwent a smooth inhaled induction, I intubated the patient's trachea while the circulating nurse prepared to place the acetaminophen suppository as per routine, during which time she stated, “Something isn't right.” I examined the patient and noted mild bruising around the anus and what I will describe as an abnormal genital finding. Further inspection revealed the presence of genital warts (this was initially hidden by his clothes). While the patient was anesthetized, I asked another anesthesiologist and 3 nurse anesthetists to examine him, and all agreed with my conclusion.
I did not know how to proceed. I began by notifying the surgeon and the facility administrator, and then called the patient's pediatrician. He suggested asking the parents to take the child for evaluation at an area clinic dedicated to the physical examination of suspected abuse victims. I doubted the parents would follow through with such a request, so I called the social work department of a nearby hospital for advice. The counselor on call documented my report and immediately filed a complaint with the local child welfare agency. I called the agency directly for confirmation and was told to keep the parents at the facility.
Surgery proceeded uneventfully and the patient emerged from anesthesia smoothly. While he remained in the recovery room, I informed the parents of my obligation to report the findings and that a social worker was coming to interview them. During this conversation, they did not appear angry or upset or even nervous; in fact, they did not look concerned at all. Their only observation was that sometimes the patient quarreled with his sibling. Soon, a caseworker and a police detective arrived at the surgery center and interviewed the medical staff involved. Then they questioned the parents and escorted them and the patient from the facility.
Later in the day, a physician assistant (PA) at the aforementioned clinic contacted me. She said she had examined the child and had a low index of suspicion for abuse. She stated that the bruising was probably venous congestion, the genital finding was likely a normal variant, and that human papilloma virus can be transmitted by caregivers during routine child care and is not diagnostic of abuse. She admitted that the child was irritable and noncooperative during the examination, but the PA was confident in her assessment nonetheless.
This should have been good news. The PA reassured me that I had made the right decision by reporting my suspicions and said the child welfare agency would follow up with home visits. I still felt sick to my stomach. Something was not right. Perhaps the sibling's medical history had misled me, but could the findings on physical examination be dismissed? Altogether, the data seemed to point to an obvious conclusion.
The incidence of child maltreatment is terrifyingly high. According to the National Child Abuse and Neglect Data System (NCANDS, compiled by the Children's Bureau, a branch of the United States Department of Health and Human Services), Child Protective Service (CPS) agencies received an “estimated 3.3 million referrals, involving the alleged mistreatment of 6.0 million children” in 2009.1 Of the referrals, 61.9% were “screened in” for a response by CPS, and approximately one-quarter of these were substantiated.1 That means 442,005 referrals were substantiated, and this only includes reported cases of child maltreatment.1 Official rates for substantiated child maltreatment may severely underestimate the true incidence; it has been postulated that 4% to 16% of children are abused each year.2
I hoped my suspicions were wrong. But if so, I felt like I had wasted the time and resources of social services, the police, and several medical professionals. I had interfered with the bond between parents and their child. Perhaps I had placed my colleagues in an awkward situation, influencing their clinical judgments to validate my own conclusion. Coworkers congratulated me for acting on my instincts, but each pat on the back just made me feel worse. It did not help to discover I would have been subject to charges of a misdemeanor if I had not reported my suspicion. And at the end of the day, I realized I was worrying about how this traumatic experience had affected me.
A few weeks later, a colleague of mine called me in desperation. She was working at the same surgery center and was dealing with a similar crisis. I explained the process of reporting and offered to help in any other way. But there was nothing else I could do, and that just might be the most frustrating part of all.
As health care providers, we have an obligation to report our suspicions and trust other professionals to take it from there. Medical professionals, in fact, are responsible for 8.2% of referrals to CPS nationally.1 My only consolation was the hope that I had raised awareness among my coworkers of our obligation, and that our patients might benefit from our vigilance.
I am afraid this is a story without resolution. I have kept in touch with the detective who has made multiple visits with a social worker to the patient's home. So far, they have found no hard evidence of abuse, but they plan to follow up periodically because, to use his words, “Something isn't right.” I know exactly what he means.
Others in my field seem to cope with this stress much better than I. Admittedly, having a child the same age as this patient makes me more sensitive to the subject. That night I held my daughter in my arms as she fell asleep. I thought of the little boy on the other side of town; were his parents tucking him into bed? Would he have troubled dreams tonight? I hoped he would sleep peacefully and forget that this day had ever happened. I knew then, conflicted though I was, I would make the same decision all over again. I pray I never have to.
Name: Stephen Harvey, MD.
Contribution: This author was the sole author.
Attestation: Stephen Harvey approved the final manuscript.
This manuscript was handled by: Peter J. Davis, MD.