How Can EMS Providers Improve to Better Identify Child Abuse?

EMS can play a big role in helping properly identify abused patients. In a study out of Denver published in JAMA, 31% of abuse patients were evaluated by a physician after their injury and were misdiagnosed.4 The average number of hospital visits before the proper diagnosis was made was 2.8. Unfortunately, 27% of these patients were re-injured when their diagnosis was missed in the initial visit.

It takes a team effort and everyone being aware of the possibility for abuse to make the right diagnosis. Vector Vieth, director of the National Child Protection Training Center, says, “The problem doesn’t cease to exist because we choose to ignore it. If you don’t ask, you’ll never know.”

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Pediatric patient assessment can be challenging for many reasons, including concerned parents, bystanders on scene, a chaotic scene, fear among all parties involved and the child’s anxiety toward the emergency responder. These challenges can be summed up with one word: distractions. Most EMS services have low pediatric call volumes and encounter a critical pediatric patient even less. Too often the healthcare provider misses key components of the pediatric assessment, which leads to overlooking significant injuries, and this problem is especially true when dealing with a suspected abuse case.

The provider must first assess every patient’s airway, breathing and circulation (ABCs). Once they ensure the ABCs are properly managed, they should proceed on to D and E. “D” stands for disability and helps establish the neurologic status of the patient. For patients with significant head injuries or trauma, tracking the patient’s neurologic status can be helpful over time and assist the providers in deciding whether the patient needs an emergent airway.

When assessing “E,” or exposure, the emergency provider must fully examine the patient, anteriorly and posteriorly. Exposure is part of the assessment that’s most commonly skipped or missed by EMS providers. You may think, “I didn’t have enough time to unclothe the patient.” But if you don’t, then you didn’t complete your primary survey.

When caring for a suspected abuse patient who’s critical, such undergarments, as a diaper can hide the key piece of the puzzle that clues providers in to suspect non-accidental trauma (NAT). Remember that the only way to become proficient at pediatric patient assessment is to do an assessment the same way every time, regardless of whether it’s an adult or pediatric patient.

Physical Findings
Physical abuse is the most commonly reported type of abuse and is manifested through bruises, burns, ligature marks, fractures and disorders involving the central nervous system (e.g., seizures). Eye injuries, such as retinal hemorrhages, can be signs of abuse as well. The most common signs of abuse are the three Bs: burns, breaks and bruises.

Bruises in the pre-ambulatory child are especially concerning. During your patient assessment, look for unusual patterns and locations of bruises. Ambulatory children will normally have bruises over extensor surfaces, such as their elbows, knees and forehead. Bruises that may cause you to suspect abuse are often discovered in locations typically covered up by clothing or are in strange places other than where children would land if they fell. These places include the back, upper arms, upper legs, abdomen, buttocks and the pinna of the ear.

It’s imperative for the EMS professional to thoroughly assess and examine every child the same way every time so you don’t miss any areas. A “sicker” child, or a call with a higher index of suspicion, is all the more reason to fully expose the patient.

Central nervous system injuries are most commonly manifested with subdural hematomas, contusions or diffuse axonal injuries. Seizures, coma and even death may occur. However, of head injury related deaths in children younger than 2 years old, 80% are due to abuse.5,6 Have you ever been called to the residence of a child having a seizure? If the child is afebrile and has no history of seizures, then child abuse should at least be on your differential diagnosis. You should be thorough in your assessment and ensure your documentation of the patient’s physical exam is accurate.

For this reason, a thorough assessment is paramount. Exposure in the primary assessment is not only critical, but it should also be required. Here’s one medic’s realization of why exposure is important.

On a nice fall afternoon, my partner and I were watching the football game when the tones went off. We responded to a call for “a child not acting right.” We arrived at the scene to find a young mentally and physically challenged girl withdrawn and tearful. Her neighbor insisted that this child was always happy and always had a smile on her face.

Obtaining a neuro assessment was going to be challenging to say the least. The only reliable source at the time was the girl’s neighbor, who called 9-1-1.

My assessment in the back of the ambulance was fairly unremarkable. There were no visible wounds or signs of trauma, except the patient had a small smear of blood on her thigh. (She was wearing shorts and a T-shirt.)

Instantly, there was a wave of nausea as intuition told me I’d have to further expose this young girl. I requested a female police officer join me as we proceeded to remove her shorts and diaper. My heart sank at the horrifying sight of blood that filled this young girl’s diaper. We transported the child to the hospital, where she spent several hours of surgery to repair the tears to her vaginal wall.

In a recent study, a new rule was devised to help better identify victims of physical abuse called the TEN-4 rule.7 The TEN-4 rule is used to help healthcare providers better differentiate between bruises caused by non-accidental trauma and accidental trauma. The TEN-4 regions consist of the torso, ears, and the neck in children younger than 4 years. Bruising in these areas of this age group and any bruising to a child younger than 4 months old should alert the provider to the high probability of child maltreatment.

Many providers reading this article may have never been to court in front of jury reading a patient care record (PCR) that they wrote five years prior. If you have, I’m sure the experience changed the way you document. If you haven’t, save yourself lots of anxiety and carefully document in the future.

The reality is that all PCRs should be written to paint the entire picture of the event. Because documentation mostly happens after the event, it’s important to remember key pieces of information so the documentation can be accurate.

When documenting a suspected non-accidental trauma case, remember that your job isn’t to assume; it’s to be as descriptive as possible in presenting the facts. The provider’s opinion doesn’t count for these cases. In fact, it may give the defense attorney ammunition against the hospital provider who documents something differently. The information should be objective, not subjective.

An excellent example would be the provider who documents bruises but then states that they’re in different stages of healing. The EMS provider may suspect this, but instead of writing that the bruises are in different stages, providers should note the size and color of each bruise.

Another important part of documentation is not to use “within normal limits” or “WNL” when describing vital signs. Remember, our job is to be objective with our documentation. Another common error providers make is to document “no obvious trauma” when a thorough assessment wasn’t performed. If you don’t look at it, you shouldn’t be documenting it. Hopefully, however, you’re looking everywhere you should be and documenting it appropriately.

Providers must document important information about the scene and the patient’s position. This is especially true when a patient is found in cardiac arrest. It’s also vital to document what you see, hear and smell, and what you’re told about the incident. Statements made by caregivers or others at the scene should be documented in quotation marks, so those statements can be attributed to the right person. This helps the police investigators check the stories of everyone involved.


Duty to Report
Remember that everyone who cares for children has a legal duty to report any suspicion of abuse. This includes physicians, nurses, respiratory therapists, EMS professionals, police and day-care workers. You don’t have to be able to prove the case to report it. You only have to suspect it. Unfortunately, many children are abused and treated for other complaints besides NAT. In fact, pediatric patients may be transported by EMS to the hospital and later discharged with other injuries or illnesses that are due to child abuse.

Although the goal is to stop the epidemic of child maltreatment, the goal of EMS should be to properly treat, document and report suspected cases of child abuse. The EMS professional should be aware of the signs and concerned with any child presenting with unusual bruises, breaks or burns to their body that don’t match the mechanism of injury, the story or the environment.

EMS professionals who suspect any type of child maltreatment must report their suspicions to the proper authorities and other healthcare providers to whom they’re relinquishing care of the patient. We all play an important role in this process and have to work together on this important issue. JEMS


Centers for Disease Control and Prevention. n.d. Child Maltreatment Prevention. In Centers for Disease Control and Prevention. Retrieved Sept. 1, 2011, from Children’s Alliance. n.d. InNational Children’s Alliance. Retrieved Sept. 1, 2011, from for Children & Families. n.d. Statistics & Research. InAdminstration for Children & Families. Retrieved Sept. 1, 2011, from C, Hymel KP, Ritzen A, et al. Analysts of missed cases of abusive head trauma. JAMA. 1999;281(7):621–626.Centers for Disease Control and Prevention. n.d. Injury Prevention & Control: Traumatic Brain Injury. In Centers for Disease Control and Prevention. Retrieved Sept. 1, 2011, from R. n.d. Children and Adolescents. In TPN Pediatric/Adolescent Archives. Retrieved Sept. 1, 2011, from MC, Kaczor K, Aldrige S, et al. Bruising characteristics discriminating physical child abuse from accidental trauma. Pediatrics. 2010;125(4):861.

Take Home Points

EMS professionals play an important role in identifying possible child abuse patients first.If an EMS provider has a concern, then it should be related to both the proper authorities and the hospital staff.A patient’s primary assessment isn’t complete without fully exposing them to document any injuries.Thorough documentation is key on these cases not just for patient care, but also in case you have to testify in court.Never document that bruises are in different stages of healing. Instead, describe the bruises.

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#DomesticViolence #ChildAbuse #SexualAssault #ProtectingMother #SecondaryTrauma #ParentalAlienation #Survivor #ProtectiveParent #Victimology #StudentOfNaturalLaw

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