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Patient Care

Poor Little Kid: Confronting Suspicious Injuries in Children

“EMS Reruns” is an advice column designed to address dilemmas you may have experienced in EMS that you did not know how to handle. But it offers you a luxury you don’t have on scene: plenty of time to think. If you think of an example like the one that follows, send it to us. If we choose to publish your dilemma, we’ll pay you $50. We don’t know everything, but we do know a lot of smart people. If we need to, we’ll contact just the right experts and share their advice with you. Send ideas c/o

It’s about 2300 hours, and you’re on your way again. It’s been a busy Saturday night: a rolled Toyota pickup full of kids, a shooting at a motel and a SWAT call just since supper. Now it’s a child with a broken arm.

The scene is a fairly new two-story home in an upscale residential neighborhood, neatly landscaped and surrounded with a perfect lawn. The home’s double front doors appear to be carved oak with massive brass handles, and there is an oval-shaped window at eye level in the horizontal center of each one. The right door is ajar, and you can hear a child crying vigorously as you carry your gear inside. There’s a small group of people in bathrobes on the sidewalk outside the residence, talking quietly.

Your first glimpse of the child grabs your attention. This kid can’t be older than three. She looks like a doll, with her pink hair ribbons and her little nightie, but she has an angulation deformity about three inches below the shoulder of her right arm. A young woman who could be her mom is doing her best to hold the child and cradle the injury at the same time. Your partner, Capt. Wood, kneels down next to the mom and gently stabilizes the arm for her. Woody’s got a way with kids. He understands a lot about them, and his manner tells you right away that something bothers him about this one.

Mom volunteers an explanation before you can ask for it: Her daughter fell down the stairs. She motions toward a single flight of stairs directly in front of you. The stairway, the living room and an adjacent hallway are surfaced with thick white carpet. You catch yourself wondering if Mom’s really avoiding your gaze or if that’s your imagination. But she is tearful. She kisses and consoles the child repeatedly. And the child seems to be responding appropriately under the circumstances, hugging her mom’s neck and telling her how much it hurts.

Q. What should you be thinking about this call, just based on your observations so far?

A. It’s too early to form conclusions based on so little information, but several things seem important. For one thing, children younger than four don’t usually suffer humeral fractures by accident. Much more often, they’re spiral breaks that occur when a grownup jerks them around by the arm. Even an adult would be unlikely to suffer a humeral fracture by falling down a carpeted stairway. More than that, it’s a little late for a three-year-old to be up at night. The hair ribbons suggest that somebody pays attention to this little girl, but maybe they don’t fit with the PJs. And finally, where’s Dad?

Q. Think you should get PD rolling?

A. That would be a great move if you found yourself at an obvious crime scene, or if somebody interfered with your care. But Mom has apparently called for your help, and she seems anything but obstructive. Considering that, maybe it’s better to stabilize the injury, treat for pain and get the child into the local ED. Once the child is safely under their care, share your observations with the physician, then document your findings as objectively as you can. You might consider the possibility that you will be invited to discuss this case again sometime—like with a detective.

Q. How much should you say about your suspicions of physical abuse on scene?

A. Not a peep. But keep your eyes and ears open. You get one shot to examine a scene like this, and you need to make the most of it. Judgments come later, and they need to be based on objective observations. For now, concentrate on observing what people say and what they do. Consider that there may be other kids in this home; you may want to bring them along to the hospital. Note the interaction between the child and everyone else on scene; that dynamic is important during the first few minutes following an incident. Try hard to avoid coloring your observations by guessing who’s guilty of what, and document your findings as impartially as you can.

It’s possible this kid was manhandled or even thrown down the stairs. Mom appears to be genuinely concerned, but she may also be a remorseful perpetrator. Dad appears to be absent, but he may not even be part of the picture here. And maybe this isn’t what it seems to be at all. You never need to rush an assessment of child abuse unless the child is clearly in imminent danger. When that’s not an issue, the assessment should be made by people who are truly qualified to make it. (Last thing you ever want to do is tip off a perpetrator on their own turf that somebody’s about to snatch their kid.)

Q. Is there anything else about this scene that could provide helpful information?

A. Those people standing on the sidewalk outside look like they’ve been to bed. What got their attention? Someone needs to question them, out of Mom’s view and earshot. They may be able to tell you something about what happened tonight, and they may be able to tell you about things that have happened in the past. To this child, and maybe even to Mom. But not if you don’t catch them before they disappear. Don’t forget to record their names and phone numbers, in case someone needs to question them later on.

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