Medical clearance? I asked as I paused at the door of Room 7. Inside, a social worker from Child Protective Services was watching over two small children. The boy wore only a man’s plaid shirt; the girl was dressed in a filthy white jumper. Someone must have reported these children for suspected child endangerment. They were here in the emergency room for a brief physical exam.
Is it for neglect or abuse? I asked.
Neglect, we think, the social worker replied. Mom left them at a bus stop.
Said she’d come back, but she never did. The worker reached out toward the girl. Now, here is Tonya. She’s four. And this is Raymond. He’s two.
Raymond stood gazing up at me, one hand gripping the social worker’s pants. He looked as if he would never let go. I pulled his shirt open and examined his chest and back, looking for marks. In the last child abuse case I’d seen, a little girl had come in with circular first- and second-degree burns scattered across her back. Cigarette burns. This kid looked okay, though, just dirty.
I knelt down to look at his sister. How are you doing, little squirt? She was a beautiful little girl, open and animated.
I’m four, she said and showed me three fingers.
Well, that’s very big, I said, smiling, and for big kids we have a big treat. We have ginger ale. Would you like some?
She nodded, eyes wide.
What do you say? the social worker prompted--an instinctual mother.
The little girl smiled even more and ducked her head in shyness. Shut up, she said. Shut up, shut up, shut up.
I looked up at the social worker, my jaw slack with surprise.
You wouldn’t believe some of the stuff that comes out of these kids’ mouths, she said.
The little girl turned to her brother and gave him a shove. Shut up, you stupid whore, she said. Get me a beer.
Child abuse, child neglect. For a doctor one of the most difficult parts of treating abused children is simply making the diagnosis. In the er this can be even more difficult because a diagnosis must often be made after only a minute or two of observation. One rule of thumb, I’ve learned, is to be suspicious of any parent who arrives in an er with an injured child and wants to leave too quickly.
One hot summer night it happened just that way. A mother had her son by the arm--he was about five--and she dragged him up to me.
How much longer is it going to be? she demanded.
It should have been obvious that we were all working as fast as we could. I had just intubated someone who had taken an overdose of antidepressants, and was rushing off to see a woman with heart failure. From where I was standing I could see into the room where the woman lay on her bed struggling to breath while a burly-looking man sat next to her, holding her hand.
Ma’am, I said, It’s going to be a little while.
Well, I don’t have a little while. My son is hurt. Something in her tone made me pause for a moment and look at her.
Dear, I said, everyone here is very sick tonight.
Don’t you ‘dear’ me. I’m going to another er. I’ve waited over two hours. I want some service.
Ed, the charge nurse, came hustling over. I put you in that room exactly ten minutes ago. He pointed emphatically at his watch. So don’t tell her you’ve been waiting for hours. He stopped next to me and whispered in my ear, I’m worried about this kid.
I knelt down to look at the whimpering child. He had obviously broken his forearm--the radius. There was swelling at the midshaft of the radius, and the arm beyond canted away at an angle. This was odd. When people fall, they generally fracture the forearm near the wrist. A fracture in the middle of the bone is much rarer and usually occurs from a direct blow. They’re called nightstick fractures because people have gotten them from defending themselves against blows from a police officer’s nightstick. This kid had such a fracture.
How did this happen? I asked the boy.
He looked up at his mother and then at me and silently drew away.
I’m leaving, the mother said, giving the child’s other arm a tug. He just stood there, rooted to the floor.
Wait, I said. I need to know.
Don’t you ‘wait’ me. I’m taking my son and I’m leaving.
I looked at her. I had seen a thousand women who were fine mothers and who looked just like her, but looks mean nothing. As I gazed up at her from where I knelt, I was sure--well, pretty sure--that she had hurt her child.
I squatted there a moment, debating this. After all, what proof did I have? Besides, she was going to another er. She said so. But I was angry. I was angry at her for yanking her child around and for being so damn unreasonable.
I’m sorry, I said, standing up. I was conscious that I was standing between this woman and the exit. You can’t go anywhere with that child.
She glared at me. What do you mean?
You can’t leave, I said. Any parent, child abuser or saint, would be angry with this order, but this wasn’t the time for second thoughts. I had taken my stand.
You mean I can’t leave?
You can, but the child can’t.
You’re crazy. She shook her finger in my face and yanked the boy’s arm.
I got angrier, much angrier--it was as if the scene was lit up by firecrackers.
The kid stays here, I said.
You, she repeated emphatically, are crazy. She yanked again at her son’s arm, but this time he pulled away from her, looking with terror at both of us.
You can’t go, I said loudly. Not until we know what’s going on here.
She tried to pass me.
Call security, I said, turning to Ed. I hadn’t noticed he’d left to take care of a drunk with a head wound dripping blood. I was alone in the hall without backup--very poor planning. If I headed for the desk, she would be out the door before I could get help.
Maggy, I shouted at the desk clerk, get security.
This is my boy, the woman shouted. I can do what I want with him.
The boy was wailing and trying to back away from her. She yanked at his arm again.
I’m telling you. It took me a moment to realize that I was the one shouting. I’m telling you, you can’t do anything you want. You can’t hurt a child, and you can’t leave until I know what’s going on. If you do, I’m going to have the police after you.
Police! she shouted. You have no idea. So don’t you dare threaten me.
She struck out at me and I ducked. At that moment, the firecrackers went out. I was willing to make a scene, but I was not prepared to be attacked. I stepped away, but she came after me, swinging with her free hand and trying to grab my clothes. She kicked me, just catching the side of my knee. As I went down, all I could see were her feet kicking near my face. When I looked up, I saw the burly man who had been sitting with his mother pin the woman to the wall. I got up and began to unpry her fingers from the boy’s forearm. As I pulled him free, security, like the Texas Rangers, came tearing down the hall.
All I could think was that the child would never forget this, me pulling him away from his mother.
She’s got my baby, the woman screamed. That bitch has my baby.
She needs to leave, I shouted at the security guards. She can’t stay here.
Let’s go, said Lenny, one of the guards. That ‘bitch’ is the doctor, and what she says goes. You gotta leave.
The woman stood, arms crossed, staring at me. Ed had come running back down the hall--he was a big guy and hard to ignore.
The doctor says you need to leave, he said, looming over her. I’m escorting you out to the waiting room, and we will talk about what you need to do next.
She allowed Ed to take her by the arm, but then glanced back at me and said, I’m going to hunt you down, bitch. I’m going to get you for this.
The doors closed. It was a large er, filled with patients and their families. Everyone stood in stunned silence. After a beat, though, the boy began to wail and the room broke into chatter.
Lenny carried the child back to a cubicle. My ankle was hurt, and I limped after them.
Are you okay? Lenny asked me.
Yeah, fine, fine, I said, but my ankle hurt like hell.
Lenny set the child down on the examining table. He was still wailing.
Let’s get this shirt off him, I said. I thought I had seen marks when I was fighting with the mother.
I had. There were two bruises on the boy’s face and bruises on both arms, oval bruises the size of thumbprints. And on his back were dozens of slender, elliptical marks--some were scars, but some were fresh and bright red. They were cord marks, abrasions from being hit on the naked back and buttocks with a loop of electrical cord. Unmistakable signs of abuse.
I traced the scars with my fingers, feeling the ridges. The child was just whimpering now. One of the nurses offered him a stuffed doll.
Sweetie, I said, as I knelt down in front of him. How did you break your arm?
He stared at me, unblinking.
Can you tell me? You don’t have to be scared. I promise no one will hurt you.
His chin shook. He looked away and said, D-d-d-d.
D-d-d-d . . . He gave up and rubbed at his eyes with the wrist of his good arm.
That’s all he would say.
The next afternoon the investigating officer, Tiny, dropped by to take a statement from me. Tiny weighs in at a good 350 pounds. I had taken care of his asthma attacks several times.
What do you think happened? I asked him.
I can’t comment on an ongoing investigation, he told me. But between you and me, it may be that the missus has been knocked around a few times by her husband, and I suspect the guy takes more than an occasional swing at the kids, especially this one.
Why hasn’t she filed a domestic violence complaint?
Tiny shook his head. He’d lose his job. In fact, he’s already been suspended. He’s a cop and there’s big trouble down at the station. Apparently some people knew about what was going on and never said anything.
Why is that?
Tiny frowned. You protect your own, I guess.
What’s going to happen?
If they charge him--and there’s a pretty good chance of that-- and if he’s convicted, he’ll lose his job. That leaves the three kids and Momma. . . . I don’t know what will happen to them.
I leaned back in the chair and studied the ceiling. What good does it do to save the child and destroy the family? I looked over at Tiny. How does this happen? Just who does this to children?
Well, Tiny said with a shrug, the kid’s dad . . . he’s a good man and all. I knew him in high school. But he drinks, and when he drinks, he gets mean. He paused, then shrugged. There’s lots of other reasons people hit kids, but this is a big one. People will behave like any kind of animal when booze is involved.
On a hunch, I pulled the medical records for the police officer’s wife. Sure enough, there were multiple er admissions for minor trauma culminating with, about six months before, an admission for multiple facial contusions and a nasal fracture from a fall down the stairs. Spousal abuse. Clearly. The problem was--though I had no memory of it--I had seen her. I had read the X-rays correctly; I had sewn up her cuts. But I had missed the diagnosis. Nowhere in my notes did I bring up the possibility of domestic violence. If I had made the diagnosis then, perhaps someone could have intervened before the child got hurt. I had my chance long before the scene in the hallway, and I blew it. I had no one to blame but myself.
As the days and then weeks passed, I tried to find out what happened to the child and the family, but I kept meeting dead ends. Tiny wouldn’t give me any information. Nobody I talked to knew the family or admitted that they did.
I wondered if the boy had been farmed out to a relative. What would he remember of the struggle and his broken arm? What about his mother? Was she a victim? She certainly was when I saw her after her fall, but what was she that day I saw her with her son? Victim or accomplice?
And what about me? Was I an unwitting accomplice by missing the diagnosis the first time? And in doing what I thought was right for a little boy that afternoon, did I ultimately make things worse? Did I destroy a family? There had to have been a better way, but what was it?
That day, I had acted. I had done what I thought I had to do. But as is so often the case in emergency medicine, I will never really know if I did the right thing.