1. Armed Forces Center for Child Protection Child Abuse in the ER Roles and Goals

2. Armed Forces Center for Child Protection The Setup  The ER Physician or Nurse becomes suspicious of abuse  The ER cannot or does not want to deal with it  The Pediatric Resident is called

3. Armed Forces Center for Child Protection Are You Alone?  Resources ? Family advocacy ? Children’s protective services ? Law enforcement  Consultants ? Pediatric attending ? AFCCP

4. Armed Forces Center for Child Protection Resources  Who should you call?  Who should come in?  Case match with the goals of the resource

5. Armed Forces Center for Child Protection Pediatric Roles and Goals  Primum non nocere ? Always hard when abuse is the concern  Treat the injury  Return the child to the best home environment available ? Determine if there is abuse ? Identify who or where the abuser is ? Arrange for the child to be elsewhere

6. Armed Forces Center for Child Protection Family Advocacy Roles and Goals  Treat military abused and abuser ? Substantiate / Unsubstantiate abuse ? Identify abuser and abused ? Provide treatment ? Inform command (no power without the support of the command)

7. Armed Forces Center for Child Protection CPS Roles and Goals  Protect children from maltreatment ? Substantiate / Unsubstantiate abuse ? Identify abuser and abused ? Identify ongoing risks to the child ? Separate high risk children from their abuser ? Take action to decrease risk over time ? Re-unify separated families

8. Armed Forces Center for Child Protection Law Enforcement Roles and Goals  Maintain public order ? Detain fleeing families with abused children ? Controlling disorderly people  Investigate possible crimes for possible prosecution ? Process rape kits ? Investigate crime scenes ? Interviews witnesses / suspects

9. Armed Forces Center for Child Protection Back to our hero In the ER  What can you do by yourself? ? History ? Physical examination ? Labs and Radiographs ? Treat the patient ? Admit to the hospital

10. Armed Forces Center for Child Protection History  Interview each verbal person separately ? Record the first explanation ? Press for high level of detail ? Identify the source of all information ? Point out inconsistency ? Record changes and additions

11. Armed Forces Center for Child Protection Physical Examination  Complete Not problem oriented ? Hidden skin surfaces (ears, scalp, palms, soles, buttocks, genitals) ? Oral cavity (frenulae, lips, alveolar ridges) ? Palpate the skeleton ? Look at the eye grounds ? Examine genitals (supine and knee chest) ? Neurological / Abdominal injuries

12. Armed Forces Center for Child Protection Laboratories  ? Bleeding involved -- PT, PTT, INR, CBC, Family history vs. Von Willebrand’s panel  Recent or significant trauma -- AST, ALT, Amylase, Urinalysis

13. Armed Forces Center for Child Protection Radiographs  Under age 2 -- Skeletal survey  Altered consciousness plus unexpected trauma in an infant -- CT scan

14. Armed Forces Center for Child Protection Treatment  Needs no elaboration

15. Armed Forces Center for Child Protection The Admission Decision  Medical indication to admit  Provide a safe environment while question of abuse and abuser is evaluated  Allows monitored contact with a possibly innocent family

16. Armed Forces Center for Child Protection When Do You Need Help?  Abuse in the home  Parents uncooperative with hospitalization  Hospital bed unavailable  Urgent exam beyond your ability  Rape kit

17. Armed Forces Center for Child Protection Reporting  UCMJ mandated report to family advocacy  MD, VA, DC law mandated report to appropriate agency ? Abuse in home -- CPS ? In the county where the child lives ? Out of home rape or assault -- Police ? In the jurisdiction where the crime occurred

18. Armed Forces Center for Child Protection Follow Up  Document encounter well ? Probable legal follow up ? Possible court testimony  Research the medical basis of the abuse question ? Member of the case evaluation team ? Advocate for the child within the system