by David Page
• Remain open to suggestions about your own conduct.
• If you can't get up the mountain on your own, don't resort to other means of transportation to get higher; you may get higher—and sicker.
Should older people with medical problems participate in activities at high altitude?
It depends on the individual. Studies have shown that older people with chronic illnesses, such as heart disease and emphysema, can tolerate altitude if they approach their activities slowly and give themselves time to acclimate. It's best to have older folks undergo an exercise stress test before taking on a major trekking, climbing or skiing trip. The first week or two are the most dangerous when the person's adrenaline rushes with exercise and the exhilaration of pristine alpine surroundings. This added strain might provoke angina or a heart attack.
The world of your story may require a character to plunge the mute, frigid waters of the ocean or scale wind-ripped, jagged peaks in Nepal. In either case, catastrophe shadows the ambivalent availability of oxygen. As you craft your disaster scene, know that danger plays hide-and-seek on every coral reef and lurks behind the innocent beauty of the ice-gilded summit.
Domestic violence is a crime. The occurrence of this outrage has been underestimated over the last several years, is frequently missed by health care professionals and tends to escalate and become chronic. Escape for the victim usually requires a support system offering both medical and legal assistance.
All ages and genders are easy prey.
As victims of traumatic injuries, children are no more small adults physically than they are emotionally or intellectually. Kids get hurt a lot. Sometimes it's a consequence of an accident. Often it's intentional.
The demon of domestic violence isn't satiated with harm to children. It sneaks behind the kids and humiliates the mother, the wife. Half of all males who abuse their female partners also abuse their children. Mostly, domestic violence involves males battering defenseless family members. Occasionally, the violence centers on women fighting back. Consider these facts:
• About three million kids each year are witness to one parent beating the other.
• Physical abuse of pregnant women is the leading cause of birth defects and infant mortality in the United States.
• In the United States, women are at greater risk of being assaulted, injured, raped or killed by a male known to them than by all unknown assailants combined.
• Abused women make up 25 to 35 percent of injured women seen and treated in emergency rooms.
• Fifty percent of all police calls are for domestic violence.
The elderly are as prone to injury as their younger counterparts. Elderly people, it is true, lose their balance, stumble and fall as a consequence of failing coordination, strength and eyesight. But some are victims of opportunistic cowards who prey on helpless, debilitated elderly people. Still others are neglected by otherwise reasonable people. Frustration and impatience are common among caregivers for the elderly. Subtle violence can make the elder's life hell. Unable to protect themselves, aged people may suffer at the same hand that attacks a mate or a child.
Despite differences in age, kids and old people are at risk to be hurt for the same reason: They are unable to defend themselves. They are dependent. They are helpless.
In this chapter, we'll discuss accidental wounds as part of the diagnostic dilemma facing the doctor caring for a case of potential abuse inflicted on women, children and the elderly. Injury pattern recognition has evolved over the last ten years, and diagnostic criteria have been established that apply to the doctor's examination as well as to x-ray evaluation. Specific patterns of common injuries are useful in diagnosing the battered individual.
Batterers leave a recognizable trail of scars. Not all injured kids, spouses and elderly have as an explanation for their injuries abuse by an adult. It's important to be sure. And while suspicion may lead to the appropriate unveiling of abuse, it may also, if misguided, destroy a family.
Herein lies fresh fodder for the writer's imagination. You must understand the clues that help to sort out domestic violence from accidental trauma.
Most hospitals have compiled documents that assist caregivers in collecting and documenting data for patient management and the prosecution of criminal acts of violence. The data presented here is modified from several medical and nursing sources.
A hospital's duty to the battered person of any age is threefold:
1. To assess the extent of injury and offer treatment.
2. To provide safety for the battered person.
3. To offer follow-up services for treatment and counseling.
The evaluation of a potential victim of physical abuse should follow several well-defined steps; medical personnel are trained to search for specific clues. In particular, the explanation for an injury must be reasonable and consistent between the victim and the person(s) accompanying the victim to the emergency room or other health care facility.
Health care workers look for the following indicators of domestic violence in the history:
• First contact with the victim reveals the condition of the person's hygiene, clothing and general appearance. Is the clothing ripped, worn, stained, recently washed?
• Is the victim attempting to hide any part of the body? Do you see obvious injuries that have a detectable cause, e.g., obvious cigarette burns, wrist abrasions from restraints, welts around the head and neck, belt buckle marks, tooth or bite marks?
• Does the explanation given for the injury seem unlikely or does the victim state she did it to herself (an explanation of self-mutilation)?
• Was there much of a delay between the time the injury allegedly occurred and the health care facility visit?
• Is there a pattern (or cycle) of visits?
• Does the accompanying person insist on remaining in the examining room, answering all of the questions for the victim, seemingly overprotective?
• Are the symptoms vague? Abused women may present for medical care complaining of obscure symptoms, such as fatigue, loss of appetite or "nerves," or with evidence of alcohol or drug abuse, eating disorders, excessive problems with pregnancy or frequent return visits to the ER.
These indicators are observed in the physical examination:
• Are the observed injuries symmetrical, for example, bruises on both arms or both legs?
• Are there obvious marks the victim tries to conceal?
• Are there several different injuries at various stages of healing, e.g., some black-and-blue bruises, some yellowish, resolving; old as well as new abrasions?
• Are there lacerations or contusions of the face, breasts or genitalia,
particularly in pregnant women?
• If there are burns, are they on the feet or hands or on the buttocks?
The only way to identify domestic violence is to ask. These findings should make nurses, doctors and other health care givers suspicious of major abuse problems in the home. The acute medical emergency that is treated by the ER doctor may not be the real problem. It may not even be close.
Battered, Bruised and Abused Kids
Trust no one—assume nothing.
—Norman Ellerstein
Since employed as cheap labor during the Industrial Revolution, and no doubt before, children have been abused by adults. Reports appeared in the nineteenth century of kids used as chimney sweeps and in coal mines, but it wasn't until the 1960s in the United States that battered and abused children began receiving the attention they deserved. Finally, sexual abuse emerged into the light of day.
Recently, the validity of some allegedly abused children's recall has come into question. But no one challenges the immensity of the problem of battered kids.
Beat-up children get a lot of attention when they arrive at the hospital. The medical team includes a pediatrician, pediatric surgeons, specially trained nurses, social workers and a host of legal beagles. From unique intravenous solutions to protective
custody, battered children receive compassionate care. It's important to get an early court date, involve protective services and provide the children with new clothes and other creature comforts. A major difficulty is determining which kids are injured innocently and which ones are battered.
What is the definition of a battered child?
It's whatever a particular state's laws say it is. And in America's polyglot society, what may be considered appropriate punishment for a naughty child in one culture may be considered excessive physical trauma in another. There's no easy answer. Usually, child abuse is considered to fall into four categories:
1. Physical abuse
2. Emotional/psychological abuse
3. Sexual abuse
4. Neglect
As a starting point, consider abuse as any physical injury or emotional distress to a child that cannot be fully explained by the circumstances of the accident or event described in the history provided by the caregivers. Look for a pattern of physical impairment or serious injury with a confusing explanation. The following are areas of child abuse:
• Injuries that risk the child's life
• Injuries leaving disfiguring marks or those requiring a prolonged convalescence
• Painful, repeated injuries
• Injuries associated with loss of function of a limb or organ
Some parental acts can be considered abusive and may blend imperceptibly into subtle as well as harsh emotional and physical assaults on a child. For example, examine the following list of behaviors. Where would you draw the line between acts you consider discipline versus child abuse?
• Scolding
• Yelling
• Shaking
• Slapping
• Strapping/spanking
• Isolating for prolonged period of time
• Hitting with a fist
• Causing multiple bruises and contusions
• Breaking bones
• Causing unconsciousness or other neurological damage
• Depriving of food and water
• Injuring with flame, sharp instruments or weapons
In your story, you must decide whether a family is relatively "normal," a little peculiar or truly dysfunctional. For example, does the mother feed, love and provide comfort for her children? Or does she get them most meals but occasionally neglects them while she's out doing for herself? Or is she overly protective? Are the kids overfed and fat? Or are they left to fend for themselves? Latchkey kids? Practically homeless waifs?
Here's the problem: Ninety percent of American parents use some form of physical discipline. Some say it's the only way to get a child's attention; others rely on the Bible for guidance. Not all parents realize their children dislike being hit and embarrassed as much as adults or that violence begets violence or that other methods of discipline, such as grounding or losing privileges, make the point and preserve a nonviolent family interaction.
Why does child abuse continue?
• Abused kids become abusing adults; they "pass it on."
• Parents become fatigued and short-tempered raising children.
• Parents may have excessively high expectations for their children and feel the children are not trying to reach their potentials.
• Parents may feel disappointment with a chronically ill or develop-mentally slow child and seek to discipline the child for being weak and imperfect.
• Child is too small, too big or the wrong sex.
• The child was unexpected.
• Parents are too young—kids having kids.
All states require that medical professionals report suspected cases of child abuse. The threshold for suspicion and its definition are not standardized, but "cause to suspect" or "cause to believe" that child abuse may have occurred is sufficient to warrant a report to the proper authorities. Some people feel too much parental behavior is being reported. Certainly the initiative is fraught with danger.
Recrimination from falsely reporting a parent as abusive may not be reversible. Is there a way to be sure? Not always. The potential for child abuse can stir conflict into the most seemingly loving domestic nest in your tale.
We'll examine a few examples of difficult diagnosis in cases of potential child abuse. The subject strains beyond the constraints of our coverage here. Useful references are listed at the end of the book for more thorough research.
Abusive Burns
Accounting for 10 percent of all types of child abuse, burns may quite often be innocently caused or accidental. When battering is diagnosed, the burns are usually of different stages and could not have been caused by a single event or agent. Some burns have a characteristic appearance, notably small round cigarette burns, often on the buttocks, hands and feet. And if associated with other types of injury, the flag of suspicion for child abuse should be hoisted. "Branding," or a recognizable pattern of burn, is almost always intentional.
Accidental burns are often from hot water, with scalds in a "splash" configuration, and may have an arrowhead shape as hot fluid flowed down the child's body. Also, accidental hot water burns are of varying depths. But an intended punitive burn, like that on a child held in a tub of hot water, is of uniform depth and degree.
Abusive Brain and Spinal Cord Damage
Infants and toddlers have unique anatomy with relatively large heads, flexible necks and other anatomic characteristics that subject them to what is called the "shaking impact injury," or the shaken baby syndrome. Severe flexion and extension of the neck associated with shaking and, at times, smacking the head against an object (e.g., a wall) cause multiple neck and brain injuries. Occurring most often in infants under the age of fifteen months, the injuries include brain bruises, torn cerebral veins and the resultant bleeding into the brain or below the membranes. The result is severe pressure on the infant's brain and a mortality rate of about 15 percent. Even if no impact occurs, half of these kids sustain significant neurologic damage.
A report of a sleepy, irritable infant who "fell off the couch" suggests child abuse. Parents who insist the baby had a seizure before arriving at the hospital must be carefully questioned and the infant evaluated for other impacts. A modified Glasgow Coma Scale (see page 70) will be recorded in the ER. Also, a CT scan of the head will be obtained by the examining doctor if head trauma or bleeding into the brain is suggested on physical examination.
If abuse is suspected, skull x-rays may reveal recent or old skull fractures, and MRI scans add the ability to diagnose very small amounts of blood in and around the brain that otherwise might have been missed. Also, MRI may demonstrate fluid-filled spaces around the brain, which mark a delay between the abusive impact and the time the parents sought medical attention for the child.
Abusive Chest and Abdominal Trauma
Kids get kicked and punched in the trunk in almost 20 percent of reported battered child cases. Children's ribs are pliable and bend with impact, and serious internal injuries are infrequent. Fractured ribs do occur as does disruption of the bone-cartilage joint ("separated ribs") near the breastbone. With a vicious attack, any of the "dirty dozen" adult injuries described in chapter seven can be produced in kids with devastating results.
Also, a child's belly isn't like yours or mine. Muscles in the youngster's abdominal wall are thin, and the flexible ribs don't hold their shape and protect abdominal organs very well. This is partly because they don't cover the upper abdominal organs as completely as mature ribs do in adults. In addition, the child's internal organs are relatively large in comparison to the volume of the abdominal cavity and the child's body size in general and are unable to absorb the forces of blunt trauma. Only about 5 percent of all child abuse damage involves injury to internal organs of the chest and abdomen.
The diagnosis of serious internal damage is not difficult for the pediatric trauma surgeon. The presence of respiratory signs such as gasping for breath, chest pain or a reluctance to breathe deeply, when coordinated with chest x-ray findings,
confirms the diagnosis. Abdominal tenderness and other clinical findings suggest the need for an emergency CT scan of the abdomen, ultrasound, peritoneal lavage or immediate surgery. Treatment is tailored to the findings. With both chest and abdominal injuries, the question may remain: Was this accidental or abusive?
X-Ray Proof of Child Abuse
Not long ago, a two-year-old was brought to our hospital with a bruised foot after stubbing his toe. The x-ray tech performed the wrong x-ray, and multiple old fractures were noted. After what seemed like endless bickering, the father admitted to abusing the child during the day when the unsuspecting working mother was absent. Only then did the mother recall the child crying whenever she left him alone with his father. Criminal proceedings were pursued.
Some mistakes work out. Wrong x-ray, right diagnosis. The child is now loved and protected by his mother and extended family.
A bone survey, a set of x-ray pictures rather than isolated films of the area of clinical concern, displays all of the child's bones. The survey provides proof that there are other injuries highly suggestive of child battering—or may show that the impact presenting to the ER is not an obvious repeat performance. Of course, isolated injuries can be the result of abuse. It's hard to be sure.
Here are a few of the diagnostic things a radiologist does in a case of suspected child abuse:
• A "babygram," or multiple x-rays of the entire child, usually done on children under two years of age. May miss injuries.
• Bone scan (radioisotope study). May pinpoint occult fractures not seen on plain x-rays.
• Skull x-rays. May show open sutures (jagged joints between skull plates) from increased pressure secondary to hemorrhage; also may show fractured skull.
• Collarbone x-rays. Used to find a midshaft break, a common abuse fracture.
• Long bone (extremity) x-rays. These show horizontal or spiral fractures from direct blows, as well as disruption of growth plates.
Other x-ray findings in battered kids include broken hand bones, "buckle" (incomplete) breaks in long bones, evidence of torn and healing ligaments, ruptured tendons and swollen soft tissue. Also, the radiologist can tell approximately when the fracture occurred. Bones with ragged-edged breaks and soft tissue swelling are recent. When bone healing is manifested by the formation of callus (the piling up of new bone around the break), the fracture is over two weeks old—probably more like a month.
