You and your partner are dispatched to care for a lethargic child. The house is in a good neighborhood and appears to be in good repair.
The interior of the home is clean and tidy. The mother leads you and your partner to a bedroom in the basement where you find 3-year-old Joshua lying on a mattress on the floor, appearing to be asleep. He’s small for his age and his skin is pale. Upon touching him, he responds by opening his eyes and moaning. He’s hot to the touch and his mother tells you he’s been increasingly lethargic for the past several days and hasn’t been eating or drinking.
Your assessment reveals he’s tachycardic and appears malnourished. There are no bruises noted on his body. When you remove his diaper you notice it’s stained with dark, yellow urine and there are open sores on his butt consistent with severe diaper rash. The mother had stepped out of Joshua’s bedroom but has returned. She said she needed to check on the other children. When your partner asks about the other children she says they’re fine and haven’t been sick.
You tell the mother you need to take Joshua to the hospital. She says that’s OK but she’ll need to meet you there later because she has no one to watch the other children until her husband arrives home. You attempt to help her find other options but eventually decide, in the best interest of Joshua, to transport to the closest ED. During transport there’s no change in Joshua’s appearance. You’re able to establish an IV and give a 20 mL/kg bolus. You gently dress the wounds on his butt and keep him warm. When transferring the patient to the ED staff you and your partner relay what seem to be odd circumstances and let the staff know Joshua’s mother will be at the hospital as soon as her husband arrives home. Talking with your partner later about the call, you both agree that your findings are consistent with possible child abuse and you follow your local protocol and notify the appropriate agency.
Child abuse can take many forms. According to the 2013 U.S. Department of Health and Human Services (HHS) report on child mistreatment, 79.5% of victims were neglected.1 Neglect includes the failure of the caretaker to provide for a child’s basic needs such as food, water, shelter, clothing, and emotional and physical stimulation. HHS also reports that 18% of abuse victims were physically abused, 9% were sexually abused and 8.7% were psychologically maltreated. In the 2013 report, almost 30% of the children abused were under the age of 3 and in over 91% of the cases, the parents were the abusers.1
EMS providers are in an interesting position and have an obligation to report suspected child abuse. We’re commonly in the homes where children are abused. Providers have the opportunity to see firsthand the living situations, family dynamics and other factors consistent with child abuse or maltreatment. Few other medical providers have this insight.
It’s up to us to recognize potential abuse or maltreatment and report it. Providers should be familiar with the processes to be followed in their area if they suspect child abuse or maltreatment.
In this case, the household and parents had been reported to social services previously and had two previous children removed from the home. The parents then had more children. The investigation launched by emergency healthcare workers resulted in the permanent removal of all three children from the home and legal action taken against the parents. The 3-year-old in the case wasn’t talking because he didn’t know how–his only method of communication was grunting. None of this information could have been known by EMS or hospital workers.
EMS providers may never know how many reported instances exist against a caretaker, and we can’t take the stance of “It’s not my concern” or “I don’t want to cause trouble for the family if I’m wrong.”
Many states have online training for EMS providers offering guidance on the reporting process. In January, Colorado initiated a statewide campaign in an effort to empower everyone in the community to watch for and report suspected child abuse and neglect. The campaign, found at colorado.gov/cdhs, uses a statement I believe is apropos: “Noticing child abuse or neglect isn’t always easy. Calling is.” Help care for and protect those who can’t stand up for themselves.
1. U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. (2015). Child maltreatment 2013. Retrieved May 27, 2015, from www.acf.hhs.gov/programs/cb/research-data-technology/statistics-research/child-maltreatment.