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Child Abuse in the ER

The Setup. The ER Physician or Nurse becomes suspicious of abuseThe ER cannot or does not want to deal with itThe Pediatric Resident is called. Are You Alone?. ResourcesFamily advocacyChildren's protective servicesLaw enforcementConsultantsPediatric attendingAFCCP. Resources. Who should you

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Child Abuse in the ER

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    1. Child Abuse in the ER Roles and Goals

    2. 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. Are You Alone? Resources Family advocacy Children’s protective services Law enforcement Consultants Pediatric attending AFCCP

    4. Resources Who should you call? Who should come in? Case match with the goals of the resource

    5. 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

    6. 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. 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. 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. 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. 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. 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. Laboratories ? Bleeding involved -- PT, PTT, INR, CBC, Family history vs. Von Willebrand’s panel Recent or significant trauma -- AST, ALT, Amylase, Urinalysis

    13. Radiographs Under age 2 -- Skeletal survey Altered consciousness plus unexpected trauma in an infant -- CT scan

    14. Treatment Needs no elaboration

    15. 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. When Do You Need Help? Abuse in the home Parents uncooperative with hospitalization Hospital bed unavailable Urgent exam beyond your ability Rape kit

    17. 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. 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

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