Sarah's last visit

If the author had done more, would the child still be alive?

By Thomas J. Richards, MD
Family Physician/Ventura, CA

She was a runny-nosed little blond girl in dirty clothes. No different at first glance from a lot of other toddlers I saw in the emergency department. She had a cough and she'd felt warm at times. Her mother thought she had a fever, although she hadn't taken the little girl's temperature.

I walked over to the gurney, introduced myself to Sarah's mother, who looked like most tired young mothers, and then turned to Sarah, as I'll call her. As I was talking to her mother, I noticed that Sarah didn't look around the way most children in the ED or clinic do. She seemed dull, apathetic. Then, as I bent down to her, she looked up at me and I saw something I rarely see. It was more than just fear; it was abject terror. I see lots of scared kids, and I understand their fear. Two-year-olds get the double whammy of stranger anxiety at about the same time they develop the ability to remember the last time someone in a white coat looked at them. Most of those visits end with a needle, and that leaves an understandably negative impression. This was different, though. This was a whole new level of fear.

When I reached out to touch her, she flinched. I started to look more carefully at her and as she moved I saw a couple of small bruises on her inner thighs. Toddlers fall, and they get bruised. Those bruises are on the extensor surfaces—the knees, the elbows, the head—but not the inner thigh. I asked Sarah's mother to undress her so I could examine her.

I watched the interaction. Sarah's mother seemed to dote on the little girl, but I couldn't shake the feeling that it was excessive. The remainder of Sarah's exam was normal—no fever, no sign of significant infection—but at one point I noticed a slightly darkened area on her chest. It looked like an old bruise, and it had roughly the shape of an adult-sized handprint.

I'd seen enough. "You know," I said, looking at Sarah's thighs, "I don't usually see bruises on that part of a child's legs. Can you tell me how they got there?"

"She falls a lot." There was no inflection, no hesitation.

"Most of the time when I see bruises from falling, though, they aren't here," I said, pointing at Sarah's bruised inner mid-thigh. "That's kind of an unusual spot."

"We have a table with legs that stick out, and she must be running into it."

I nodded thoughtfully.

"What about that mark on her chest? It looks like a handprint."

"Oh that. Well, the other day my boyfriend was going to give Sarah a bath and he put her in the tub, but when he went to turn the water on it came out too hot so he pulled her out of the tub really quick so she wouldn't get burned. I guess he squeezed her a little too hard."

"You're sure that's what happened?"

"Oh, yeah. He told me about it right away."

"Is your boyfriend alone with Sarah very often?" I asked.

"No. I'm home all the time," she said.

"You don't work."

"Not now."

"Look," I said, "I'm not accusing you of anything, but I'm concerned about these bruises and I need to know if it's possible that anyone could be hurting Sarah."

"No. I'm with her 24 hours a day."

"And you're not hurting her?"

"No." She smiled down at Sarah.

I wasn't sure what to do. I was fresh out of residency and working double coverage shifts in a busy community emergency department. The other docs in the group were all more experienced than I was, and I frequently consulted them. That night Dave Palmer was on with me. Dave is a terrific doc and a good teacher. I told him about Sarah. I planned to fill out the child protective services form, and I had a call into Dr. Eastes, the pediatrician who usually took care of Sarah. I wanted to ask if he had ever had similar concerns about Sarah and if he'd see her the next day. When I told Dave my plan, he thought for a moment and said, "That sounds good."

Dr. Eastes called back. He remembered Sarah and had even seen her in the past couple of weeks. There was nothing to suggest abuse from what he remembered, but he agreed to see her the next morning for follow-up.

I told Sarah's mother that I wanted to have Sarah rechecked in the morning at Dr. Eastes' office and that I'd spoken with Dr. Eastes, who was expecting them. I also told her that the state required me to report all cases of suspected child abuse to the CPS office and that they would be contacting her. She nodded blandly and asked if she could take Sarah home now.

I sighed. "Yeah. Thanks for bringing her in."

Our ED encounter form had a spot on it labeled "MDM" with a space next to it. MDM stood for medical decision-making. It was a place for us to write any particular concerns that we had in case the patient was seen in follow-up by one of our colleagues. Often that included differential diagnoses that we thought should be considered if the patient was seen again for the same or similar problems. I wrote 'suspect child abuse' in the space.

Eleven days after I'd seen Sarah in the ED, I was leaving a restaurant when I happened to glance into the newspaper dispenser on the sidewalk. The headline read something like "Child Beaten to Death in North County." Inset was a picture of Sarah. I fumbled for some change as a wave of nausea welled up inside me. The story told how she had been brought back to the same emergency department I'd been working at that night. This time, she was in cardiac arrest. Her body was badly bruised; cigarette burns marred her skin. The preliminary cause of death was abdominal trauma.

We each had a box in the emergency department office for follow-up reports and mail. When I returned to work in the ED two days later, the note from Sarah's last visit was stapled to the one I'd filled out. The doc who'd seen Sarah that night had scrawled 'You were right' on a scrap of paper and paper-clipped it to the top.

Over the next couple of days, I tried to piece together what had happened between Sarah's leaving the hospital on the night I saw her and her death a week and a half later. I wanted to know what had gone wrong.

I found out that Dr. Eastes did see Sarah the next morning. He didn't notice any suspicious bruising, and the child looked fine. The social workers had gone to Sarah's home and a brief visit didn't reveal any problems, so they left. Unfortunately, they didn't find out that Sarah's mother's boyfriend was out on probation for violent offenses. Later, during the trial, it would come out that he had been the one to beat Sarah to death.

I could have hospitalized Sarah. Certainly, in retrospect, I should have. I thought that Sarah needed more than just my suspicion on her side. So I let her go. I was busy and thought I'd done enough. There's no telling if doing more might have changed the outcome but, of course, you always wonder.

There is an ICD-9 code for child abuse. If you ever find yourself sitting late at night looking at a child and asking yourself, "Should I admit this child?" think long and hard about using that code on some admit papers.

 

Thomas Richards. Sarah's last visit. Medical Economics 2002;4:47.