PERSPECTIVE
knowing what it actually means. We should celebrate, not obstruct, the many physicians who have stepped up to remind us. Disclosure forms provided by the author are available with the full text of this arti cle at NEJM.org.
U .S. T R A IN E E S A N D T H E
E B O LA E P ID E M IC
This a rticle was pu blished on D ecem ber 17,
N ichol S. Ebola 2014 — new challenges, new
2014, at NEJM.org.
global response and responsibility. N Engl J
1. Sham asunder S, Le P. U niversity doctors:
4. W ildes R, Kayden S, G oralnick E, et al.
we need m ore s u p p o rt fig h tin g Ebola in A f
Sign me up: rules o f the road fo r h u m a n ita r
rica. H u ffin g to n
ian volunteers d u rin g th e Ebola outbreak.
M ed 2014;371:1177-80.
Post. O c to b e r 29, 2014
(h ttp ://w w w .h u ffin g to n p o s t.c o m /s rira m
D isaster M ed Public H ealth Prep 2014 O c to
-sh a m a su n d e r-m d /u n iv e rs ity -d o c to rs
ber 24 (Epub ahead o f prin t).
-support-eb ola_ b_60 559 44.h tm l).
5. Sunstein CR. Laws o f fear: beyond the pre
2. W illyard C. U niversity travel bans and
ca u tio n a ry p rin cip le . C am bridge, England:
quarantines may im pede Ebola response.
C am bridge U niversity Press, 2005.
Dr. R osenbaum is a n a tional c o rre sp o n d e n t
N at M ed 2014;20:1359.
DOI: 10.1056/N EJM pl415192
fo r th e J o u rn a l.
3. Frieden TR, D am on I, Bell BP, Kenyon T,
C opyright © 2 01 4 M assachusetts M e d ica l Society.
A S tr u g g le fo r C e r ta in ty —
P ro te c tin g th e V u ln e r a b le
Stephanie A. Deutsch, M.D.
J \ . r e you sure? I ask myself. I stand there listening, watch ing, as the couple describe their house, its picket fences, their dog, the swing set in the backyard. Are you really sure? The question asserts itself again, in tempo with the ventilator’s rhythmic whoosh. Are we sure we’re sure? Like a siren gaining volume, these piercing words distract me, threatening to derail my focus. I’m here to de liver news that won’t be well re ceived. I glance at my patient, an infant lying peacefully in his hos pital crib, cherubic features ob scured by the tape securing his endotracheal tube. A large sub dural hemorrhage was visible on his CT scan, and the radiologist just called with more bad news: healing posterior rib fractures diagnosed on a skeletal survey. Surely there’s been a mistake, I tell the radiologist, but my sug gestions of overlying artifact or poorly penetrated films can’t cast any uncertainty on his diag nosis. The x-rays are nearly iden tical to images in my textbook labeled “highly suspicious for child abuse” — bulbous bony calluses defiling the otherwise smooth contours of the ribs. Ab sent a reported history of trauma,
506
my hope of deeming this con stellation of clinical findings ac cidental is further quashed by the ophthalmologist’s description: “multilayered retinal hemorrhages extending out to the periphery, too numerous to count, highly concerning for nonaccidental trauma.” Focus, I tell myself, as I con sider the mild-mannered woman sitting before me, her gainfully employed, well-educated husband leaning on the guardrail o f his son’s hospital bed. I’m finding all this hard to reconcile. The parents of this damaged infant seem so pleasant, even charming, their docile demeanors juxtaposed with multiple injuries without known cause. Detach the facts from the people, I remind my self I’m here to tell his parents I’ve called child protective ser vices, and they’re under investi gation for child abuse. We had met briefly in the emergency department when the ambulance first brought their son in. His father had found him, a fragile infant only a few months old, seizing in his crib during a nap. When we met, they seemed worried, visibly scared, and I re member looking into the moth
N E N G LJ M ED 3 7 2 ;6
NEJM .O RG
FEBRUARY
5, 2 01 5
er’s eyes while gathering my his tory of present illness. I had felt somewhat guilty, probing for de tails at a time like that, looking for suggestions o f a history of nonaccidental trauma. They had moved to this town a few weeks ago, a job transfer prompting them to abruptly pack up their former life several states away and leave family, friends, trusted babysitters behind. Their sched ule seemed a blur of per diem shifts and weekend work, with shared child-care responsibilities wedged between, and the mother painstakingly recounted the home remedies for colic she’d tried on the pediatrician’s advice. Nothing had seemed to work, she said. I’d briefly mulled over the possible dynamics — crying infant, frus trated caregiver — as the knowl edge o f the medical findings weighed on me. Looking at them, I’d asked myself, Is there anything else you can th in k of? I’d wished there was. I’d wanted to exhaust all the possibilities. As a pediatrician who assesses children for possible abuse, I grap ple with uncertainty every day. Knowing that a child’s safety may be in my hands, I must weigh the objective evidence to determine
PERSPECTIVE
whether the signs and symptoms represent the effects of abuse. For me, the question is one of proba bility, whether mechanistic and historical explanations incongru ous with clinical reality exceed my threshold o f suspicion for report ing to child protective services. Differentiating between inflicted and accidental injury to a “reason able degree of medical certainty” — the criminal courts’ lingo — can be complex, at times far from satisfactory to investigators seek ing immediacy and omniscience. Even the most unequivocal radiologic and laboratory studies can prove challenging when the knowledge of the gravity of my decisions threatens to sabotage my actions. Though I ultimately defy the temptation to let feelings sway my judgment, I must ac knowledge that sometimes I’m tempted. I may feel sadness or anger over the injuries I assess, or frustration with an overburdened protective services system tasked with the near-impossible mission of ensuring the safety and well being of the most vulnerable. Then there are subconscious biases that shape all human in teraction. Are you sure? sounds decibels louder when I find the family likable — when I can imagine myself bumping into them at the local supermarket or in the school parking lot. The more likable they are, the harder it may be to conceive of them be ing responsible for the child’s in juries. And seeing them as “like me” creates the hardest situation o f all. Most complicating may be the burden of knowing that my as sessments could radically change the lives of a child and family forever: thanks in part to my medical impression, a child may
A
grow up distant from his or her parents, safety taking precedence over biology. Child abuse is never simple, never not complicated. I take solace in knowing I can’t possibly be alone in this confusion. It’s not all up to me, this quagmire o f probabilities, imminent risk, and children’s best interests. We work as a team, the medical provider buffered by the independent assessments o f so cial workers, caseworkers, and police who collectively determine the probability of future harm and the necessary steps to safety. The definitions, criteria, and prac tices we each use to stratify lev els o f concern and involvement entangle us in a marriage of ne cessity, with the goal o f doing what’s best for children. Sometimes our relationship works harmoniously, when the gravity of a child’s injuries and the degree of medical certainty prompt swift action, and the child is protected by the provi sion of safety planning and sup port for the family and the per petrator is punished. Sometimes we disagree about the likelihood of future harm, and our discord threatens to taint our impres sions of the family’s functional ity. There’s a rawness to these investigations — a vulnerability that can affect the caseworkers, social workers, and police offi cers as they uncover what lies be hind the walls of a home where a child may grow up, safely or un safely, on the basis of their judg ment. Yet we must all form our opinions and make judgments, and when we’re wrong there are consequences. Child protection is a complex gamble on successful parenting and happy childhoods. I often struggle to reconcile the injuries I’ve found with the
N E N G L J M E D 3 7 2 ;6
N E J M .O R G
FE B R U A R Y
5,
2015
S T R U G G LE
FO R
C E R T A IN T Y
tragic knowledge that they were sustained at the hands of a human being, a hand I may have held in consolation or support at the bed side of a battered child. It is chal lenging to weigh what I know to be true against what I wish were the case. But I can’t allow the sound medical evidence of x-rays revealing “classic” injuries con sidered “pathognomonic” for child abuse to be trumped by emotion’s rose-colored glasses. Every case, every family, and every interaction is different. I be lieve that in this field more than most areas of medicine, we should strive to embody the tabula rasa, approaching each encounter free from preconceived notions, ste reotypes, and judgments in formed by ZIP Code, income lev el, or skin color. Though we can’t erase the experiences that define us as individuals and shape our reception and expression, our in teractions with other people, we can strive to recognize, manage, and understand these influences on our actions and thoughts. I look back down at my pa tient, his healing rib fractures, acute brain injury, and retinal hemorrhages revealing a tragic truth about his safety. I am one of society’s sentinels, tasked with identifying children who’ve been injured by those responsible for their care, and I must start the process of protection. I feel a little more clarity as I look back up at his parents, more secure in my medical opinion, and I begin the conversation. Disclosure forms provided by the author are available with the full text of this article at NEJM.org From Children’s Hospital o f Philadelphia, Philadelphia. DOI: 10.1056/NEJMpl409627 C opyright © 2015 M assachusetts M e d ical Society.
507
Copyright © Massachusetts Medical Society 2015.
knowing what it actually means. We should celebrate, not obstruct, the many physicians who have stepped up to remind us. Disclosure forms provided by the author are available with the full text of this arti cle at NEJM.org.
U .S. T R A IN E E S A N D T H E
E B O LA E P ID E M IC
This a rticle was pu blished on D ecem ber 17,
N ichol S. Ebola 2014 — new challenges, new
2014, at NEJM.org.
global response and responsibility. N Engl J
1. Sham asunder S, Le P. U niversity doctors:
4. W ildes R, Kayden S, G oralnick E, et al.
we need m ore s u p p o rt fig h tin g Ebola in A f
Sign me up: rules o f the road fo r h u m a n ita r
rica. H u ffin g to n
ian volunteers d u rin g th e Ebola outbreak.
M ed 2014;371:1177-80.
Post. O c to b e r 29, 2014
(h ttp ://w w w .h u ffin g to n p o s t.c o m /s rira m
D isaster M ed Public H ealth Prep 2014 O c to
-sh a m a su n d e r-m d /u n iv e rs ity -d o c to rs
ber 24 (Epub ahead o f prin t).
-support-eb ola_ b_60 559 44.h tm l).
5. Sunstein CR. Laws o f fear: beyond the pre
2. W illyard C. U niversity travel bans and
ca u tio n a ry p rin cip le . C am bridge, England:
quarantines may im pede Ebola response.
C am bridge U niversity Press, 2005.
Dr. R osenbaum is a n a tional c o rre sp o n d e n t
N at M ed 2014;20:1359.
DOI: 10.1056/N EJM pl415192
fo r th e J o u rn a l.
3. Frieden TR, D am on I, Bell BP, Kenyon T,
C opyright © 2 01 4 M assachusetts M e d ica l Society.
A S tr u g g le fo r C e r ta in ty —
P ro te c tin g th e V u ln e r a b le
Stephanie A. Deutsch, M.D.
J \ . r e you sure? I ask myself. I stand there listening, watch ing, as the couple describe their house, its picket fences, their dog, the swing set in the backyard. Are you really sure? The question asserts itself again, in tempo with the ventilator’s rhythmic whoosh. Are we sure we’re sure? Like a siren gaining volume, these piercing words distract me, threatening to derail my focus. I’m here to de liver news that won’t be well re ceived. I glance at my patient, an infant lying peacefully in his hos pital crib, cherubic features ob scured by the tape securing his endotracheal tube. A large sub dural hemorrhage was visible on his CT scan, and the radiologist just called with more bad news: healing posterior rib fractures diagnosed on a skeletal survey. Surely there’s been a mistake, I tell the radiologist, but my sug gestions of overlying artifact or poorly penetrated films can’t cast any uncertainty on his diag nosis. The x-rays are nearly iden tical to images in my textbook labeled “highly suspicious for child abuse” — bulbous bony calluses defiling the otherwise smooth contours of the ribs. Ab sent a reported history of trauma,
506
my hope of deeming this con stellation of clinical findings ac cidental is further quashed by the ophthalmologist’s description: “multilayered retinal hemorrhages extending out to the periphery, too numerous to count, highly concerning for nonaccidental trauma.” Focus, I tell myself, as I con sider the mild-mannered woman sitting before me, her gainfully employed, well-educated husband leaning on the guardrail o f his son’s hospital bed. I’m finding all this hard to reconcile. The parents of this damaged infant seem so pleasant, even charming, their docile demeanors juxtaposed with multiple injuries without known cause. Detach the facts from the people, I remind my self I’m here to tell his parents I’ve called child protective ser vices, and they’re under investi gation for child abuse. We had met briefly in the emergency department when the ambulance first brought their son in. His father had found him, a fragile infant only a few months old, seizing in his crib during a nap. When we met, they seemed worried, visibly scared, and I re member looking into the moth
N E N G LJ M ED 3 7 2 ;6
NEJM .O RG
FEBRUARY
5, 2 01 5
er’s eyes while gathering my his tory of present illness. I had felt somewhat guilty, probing for de tails at a time like that, looking for suggestions o f a history of nonaccidental trauma. They had moved to this town a few weeks ago, a job transfer prompting them to abruptly pack up their former life several states away and leave family, friends, trusted babysitters behind. Their sched ule seemed a blur of per diem shifts and weekend work, with shared child-care responsibilities wedged between, and the mother painstakingly recounted the home remedies for colic she’d tried on the pediatrician’s advice. Nothing had seemed to work, she said. I’d briefly mulled over the possible dynamics — crying infant, frus trated caregiver — as the knowl edge o f the medical findings weighed on me. Looking at them, I’d asked myself, Is there anything else you can th in k of? I’d wished there was. I’d wanted to exhaust all the possibilities. As a pediatrician who assesses children for possible abuse, I grap ple with uncertainty every day. Knowing that a child’s safety may be in my hands, I must weigh the objective evidence to determine
PERSPECTIVE
whether the signs and symptoms represent the effects of abuse. For me, the question is one of proba bility, whether mechanistic and historical explanations incongru ous with clinical reality exceed my threshold o f suspicion for report ing to child protective services. Differentiating between inflicted and accidental injury to a “reason able degree of medical certainty” — the criminal courts’ lingo — can be complex, at times far from satisfactory to investigators seek ing immediacy and omniscience. Even the most unequivocal radiologic and laboratory studies can prove challenging when the knowledge of the gravity of my decisions threatens to sabotage my actions. Though I ultimately defy the temptation to let feelings sway my judgment, I must ac knowledge that sometimes I’m tempted. I may feel sadness or anger over the injuries I assess, or frustration with an overburdened protective services system tasked with the near-impossible mission of ensuring the safety and well being of the most vulnerable. Then there are subconscious biases that shape all human in teraction. Are you sure? sounds decibels louder when I find the family likable — when I can imagine myself bumping into them at the local supermarket or in the school parking lot. The more likable they are, the harder it may be to conceive of them be ing responsible for the child’s in juries. And seeing them as “like me” creates the hardest situation o f all. Most complicating may be the burden of knowing that my as sessments could radically change the lives of a child and family forever: thanks in part to my medical impression, a child may
A
grow up distant from his or her parents, safety taking precedence over biology. Child abuse is never simple, never not complicated. I take solace in knowing I can’t possibly be alone in this confusion. It’s not all up to me, this quagmire o f probabilities, imminent risk, and children’s best interests. We work as a team, the medical provider buffered by the independent assessments o f so cial workers, caseworkers, and police who collectively determine the probability of future harm and the necessary steps to safety. The definitions, criteria, and prac tices we each use to stratify lev els o f concern and involvement entangle us in a marriage of ne cessity, with the goal o f doing what’s best for children. Sometimes our relationship works harmoniously, when the gravity of a child’s injuries and the degree of medical certainty prompt swift action, and the child is protected by the provi sion of safety planning and sup port for the family and the per petrator is punished. Sometimes we disagree about the likelihood of future harm, and our discord threatens to taint our impres sions of the family’s functional ity. There’s a rawness to these investigations — a vulnerability that can affect the caseworkers, social workers, and police offi cers as they uncover what lies be hind the walls of a home where a child may grow up, safely or un safely, on the basis of their judg ment. Yet we must all form our opinions and make judgments, and when we’re wrong there are consequences. Child protection is a complex gamble on successful parenting and happy childhoods. I often struggle to reconcile the injuries I’ve found with the
N E N G L J M E D 3 7 2 ;6
N E J M .O R G
FE B R U A R Y
5,
2015
S T R U G G LE
FO R
C E R T A IN T Y
tragic knowledge that they were sustained at the hands of a human being, a hand I may have held in consolation or support at the bed side of a battered child. It is chal lenging to weigh what I know to be true against what I wish were the case. But I can’t allow the sound medical evidence of x-rays revealing “classic” injuries con sidered “pathognomonic” for child abuse to be trumped by emotion’s rose-colored glasses. Every case, every family, and every interaction is different. I be lieve that in this field more than most areas of medicine, we should strive to embody the tabula rasa, approaching each encounter free from preconceived notions, ste reotypes, and judgments in formed by ZIP Code, income lev el, or skin color. Though we can’t erase the experiences that define us as individuals and shape our reception and expression, our in teractions with other people, we can strive to recognize, manage, and understand these influences on our actions and thoughts. I look back down at my pa tient, his healing rib fractures, acute brain injury, and retinal hemorrhages revealing a tragic truth about his safety. I am one of society’s sentinels, tasked with identifying children who’ve been injured by those responsible for their care, and I must start the process of protection. I feel a little more clarity as I look back up at his parents, more secure in my medical opinion, and I begin the conversation. Disclosure forms provided by the author are available with the full text of this article at NEJM.org From Children’s Hospital o f Philadelphia, Philadelphia. DOI: 10.1056/NEJMpl409627 C opyright © 2015 M assachusetts M e d ical Society.
507
Copyright © Massachusetts Medical Society 2015.
