I've seen my fair share of patient abuse cases working in the ER. They are always gut-wrenching. But one experience, in particular, has stayed with me.

A case of abuse that broke my heart

One day, a young mother brought her 4-month-old baby boy into the ER, telling me he was "tired" and "responding less than normal." Tests and scans determined a subdural bleed—something I had never seen in a baby. My heart sank. 

Then came a difficult conversation. I explained to the mother that it was my duty to report this case to the Department of Child Safety (DCS), and asked her the uncomfortable but necessary questions. Had she left her baby alone with another caretaker? Was she under extreme stress?

I didn't want to assume she was the suspect, but statistics show that the caretaker or someone close to the child is often the perpetrator in child abuse cases.

When DCS arrived, the baby was listless, wasn't crying, could not track, and had reduced reflexes. After multiple interviews with DCS and the police, the mom admitted to shaking her baby until he stopped crying. The medical team was confident this child would have lifelong morbidities. Yet the baby was eventually released to his grandmother, with whom the mother lived. I was angry at the mom, mad at the legal system, and heartbroken for the baby and his future.

Before he left the hospital, I cared for the baby every night. I held him while I wrote my notes. I tried to put myself in his mother's shoes, tried to understand what would drive her to shake her baby until she tore the blood vessels in his brain. I could not.

Recognizing abuse can be tricky

As clinicians, we are in a unique position to witness the effects of abuse—whether it's elder, child, or domestic abuse. But some signs of abuse are more obvious than others. One of my worst fears is being so rushed that I miss subtle signs of abuse, especially in a pediatric or an elderly patient.  

Keep your eye out for the following scenarios, which may raise red flags:

• A patient who frequently comes into your clinic or ER for STD testing (potential sexual abuse or human trafficking)

• A child who repeatedly comes to your office or ER with injuries from sports or "accidents" (potential child abuse).

• An elderly patient who presents with unexplained mood changes, physical injuries, bedsores, dehydration, or malnutrition (potential elder abuse). 

You suspect abuse, now what?

As a medical provider, you are in a position to be your patient's advocate. Here are some guidelines to follow when talking with a patient you think may have been abused:

• Always interview the patient alone (even if that means asking a family member or loved one to leave the room).

• Consider having a nurse chaperone in the room with you.

• Ensure your patient’s safety. 

• Do your best to remain calm.

• Try to establish trust.

• Practice empathy and compassion. 

• Ask appropriate questions.

• Do not place blame. 

Always report suspected abuse

Reporting abuse is a universally uncomfortable situation that can result in aggressive or violent confrontations with the perpetrator. It can make you doubt yourself and your medical practice. And putting a family through the long, stressful, and tedious evaluation process with social services can be heart-wrenching.

What if you are wrong? But what if you are right and potentially save a patient's life? 

The risk for recurrence of abuse is highest in the first 30 days after the initial episode. Therefore, if you believe in good faith that a patient is being abused, you must report it to the proper authorities.

Remember, it is your responsibility to report your suspicions, not to determine if abuse or neglect occurred. As the physician, you can only see a small piece of the puzzle in your clinical setting. Trained professionals and authorities will determine whether abuse occurred and conduct an investigation.

Be precise in your documentation of suspected abuse: Include your entire history and exam notes for other providers who may see this patient and notice warning signs. This way, a pattern can be documented, and you can be protected in court. 

Reporting guidelines can vary by state

Be familiar with your state's reporting statutes as well as the agencies empowered to investigate. Failing to report abuse can result in criminal prosecution and severe consequences for you as a physician and individual—and put your patient's life at risk if the abuse happens again. 

• Always inform your patient about requirements to report abuse.

• Obtain your patient's informed consent when reporting is not required by law (domestic violence, for example).

Although domestic abuse is not considered mandatory to report in all 50 states, there are instances where you are required to report to law enforcement, especially if injuries occurred with a firearm or deadly weapon. Be aware of the requirements in your state.

Also, keep in mind:

• If there is domestic abuse, consider the likelihood of child abuse. Child abuse is often a marker for domestic violence.

• Screening for intimate partner and infant abuse is an essential component of your history for every patient visit, including during pregnancy and well-child checkups. Screening for infant abuse is a priority when infant prematurity or disability exists due to the increased risk of decreased bonding and caregiver stress.

• The majority of neglected or sexually abused children will not have physical signs on examination. Therefore, knowledge of child development and behavior is important, along with appropriate screening questions about their home and school environments. 

• Children under 11 years of age who witness domestic violence have a high likelihood of developing PTSD.

• Provide resources such as shelters, helplines, and social welfare services that can help the victim.

Remember to take care of yourself

After reporting to the appropriate agency, make sure you care for yourself. Dealing with patient abuse as a physician is heavy. It can take a mental and emotional toll, especially if you have been a victim of abuse in the past. Memories of your past abuse and trauma can quickly re-surface, resulting in unhealthy behaviors and poor judgment. 

• Take time to process your thoughts and emotions. 

• Talk to a therapist.

• Lean on your support system.

• Practice self-care.

• Avoid alcohol and drugs to numb your feelings.

• Ask for time off of work if you feel triggered or your decision-making is compromised. 

Sources

1. US Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. Child Maltreatment 2019.

2. American Academy of Pediatrics. Children's health topics: child abuse & neglect. 2008.

3. Gupta M.  Mandatory reporting laws and the emergency physician. Ann Emerg Med. 2007;49(3):369-376.

4. Ackerman PT, Newton JEO, McPherson WB, Jones JG, Dykman RA. Prevalence of post traumatic stress disorder and other psychiatric diagnoses in three groups of abused children (sexual, physical and both) Child Abuse and Neglect. 1998;22:759–774.

5. Reiniger A, Robison E, McHugh M.  Mandated training of professionals: a means for improving reporting of suspected child abuse. Child Abuse Negl.1995;19(1):63-69.

6. Chapman DP, Dube SR, Anda RF.  Adverse childhood events as risk factors for negative mental health outcomes. Psychiatr Ann. 2007;37(5):359-364.

7. Flaherty EG, Sege RD, Griffith J, et al.  From suspicion of physical child abuse to reporting: primary care clinician decision-making. Pediatrics.2008;122(3):611-619.

8. Chalk R, King P. Health care interventions. In: Chalk R, King PA, eds. Violence in Families: Assessing Prevention and Treatment Programs. Washington, DC: National Academy Press; 1998:223-224.