Coping c child abuse

Pediatric Critical Care Columnist · Dec 5, 2006

It is really hard to be professional with these parents sometimes. It's painful to have to be polite and helpful and offer family-centered care when the parent is the abuser. But often times the facts of the abuse haven't all come out when the child is admitted; when there are multiple caregivers it's sometimes impossible to identify the perpetrator.

The first case I ever was involved in was while I was still on orientation. The patient was a 9 month old girl who came in with septic shock from peritonitis. The imaging wasn't really helpful in revealing the exact cause so she went to the OR for exploration. I asked if I could help readmit her after her surgery, thinking it would be good experience for later. :idea: The surgeon came to the unit with her and told us that her small bowel was ruptured; this kind of injury in an infant or toddler is NEVER accidental. He said the only way she could have gotten this way was by being stomped on. We were all reeling from that, but got to work with the admission. I was doing the tasks of admission: sorting out lines, transferring drips to pumps, calibrating transducers, measuring output, getting the low suction going and the rest of the drill. I was really not prepared for what I discovered when I went to replace her rectal temp probe. Her orifice had been torn from the introitus of her lady parts posteriorly to her coccyx. It wasn't a new injury, there was no redness or swelling or any sign of bleeding, and no one had documented it. I was nearly sick to my stomach. What made me sicker still was that no one was ever charged with these heinous acts. When she died the following day, I was relieved.

The following year, we had a spate of shaken babies, all nine month old girls, all shaken by their fathers, all died. The dads were all charged, pleaded out and got two years less a day in a medium security facility.

Recently I cared for a three month old who had a 4 cm tear at the base of her tongue. The dad was alone with the baby when the bleelding was noted. The aunt convinced the mom to disclose that the dad was abusive to her and the baby was apprehended.

I prefer informal debriefing with other nurses in my unit when I have patients like these. I don't find that the one-size-fits-all approach of critical incident stress management is all that helpful. The buzzwords and platitudes aren't my schtick. Our chaplain is always willing to talk to us individually and she's really supportive in whatever method of debriefing we choose. At the end of the day, I think it helps to remember that these families are really few and far between and that someone needs to care for the children.

Elvish, BSN, DNP, RN, NP · Dec 5, 2006

Thanks for the thoughtful response. People who do things like what you described above are SICK. My hat is off to you for caring compassionately for (and about) these kids.

I don't work critical care as previously stated, but we deal with our fair share of sad situations and we debrief amongst ourselves more often than not. Again, thanks.

MissJoRN, RN · Dec 8, 2006

It's hard. It's really hard when you pick up the paper a week after running down to the ER to help with a baby with cerebral edema and retinal hemorrhaging to read that the death was accidental.

I'm in general peds not PICU so I try to take solace in thinking about how many times we admit a barely sick or barely hurt child for "observation" and "rehydration" just to give social services a little more time. I think of the 9 mos old baby who was admitted several times for "fluff" and cuddled into my neck and then got a safe, caring foster home.

I hug and kiss my child a lot. Those cases make me angry and stay with me but are "easier" in their own way than many of the accidental traumas and medical tragedies that make me worry for my own child.

By the way I just finished reading "A Man Called Dave" today, sequel to "A child called It" and "The Lost Boy" but it can be read alone- what an emotional, heartwarming story of a young man recovering from one of the worst abuse cases in California (at least up until the 70s) His case changed a lot of laws and he became a great child abuse advocate. Dave Pelzer's Official Website

BSNtobe2009 · Dec 8, 2006

Call me cold, but I think in cases of severe child abuse, the courts and social services should be able to expedite the process of having the child available for adoption WITHIN DAYS.

A healthy baby, black or white, especially if it is under two, always finds a home and people are beating down the door to adopt these children.

Parents that physically harm their children to this extent....just don't need to be given a second chance. Give the BABY a second chance by finding a new, loving family.

MissJoRN, RN · Dec 9, 2006

I agree. It's amazing how parental rights can drag on for years and as long as mom makes that single one hour visit per year (or whatever the minimum is) the child is not able to be adopted. Why give an abusive parent one more outlet to control and spite a child? I also have a hard time with social services taking one child with enough evidence of being abused and leaving others in the home or mom just having another baby the next year. I just don't get it??

Elvish, BSN, DNP, RN, NP · Dec 10, 2006

I used to run into that all the time in my former job and on occasion where I am now. We used to hear, "Well, they haven't done anything to this child yet." So I guess you are going to wait until they find this kid dead??

Divergirl · Dec 17, 2006

What I find most disturbing regarding child abuse is the lack of punishment the abusers face. There was a 4mo that presented to our ER. Almost every bone in this poor child's body had been broken. We transfered her to a larger facility, however she died the next day. The abuser only received one year in jail. He committed MURDER!! And simply because she was an infant, he was not punished. I am glad I do not have to deal with these types of cases frequently.

Trauma Columnist · Dec 17, 2006

I happen to live in central IL. In our news is the mother and boyfriend who placed her three children in their car seats and drove them into a lake - needless to say they all died. The boyfriend got life w/o parole, mommy is set to be sentenced in Feb - she could get probation only! Who speaks for these dead children?

PICURN74, ASN, RN · May 1, 2007

sadly I see more child abuse cases than most as I work in a large city hospital that often gets the worst of the worst. It is terribly difficult to deal with the emotional aspects but personally I take great satisfication in providing care for patients who obviously don't get a lot of care at home. I have had to clench my teeth and face the parents of children with obvious abuse and had to resist the urge to lash out at them. It is amazing how well the children come through the abuse though and the response they show when shown a little bit of what life is suppose to be like; a safe place to sleep, some food and most importantly some positive attention and affection often brings me to tears. I find talking to other nurses in my unit and our Psych CNS help as I try to never bring those aspects home to my own family.

PICURN74, ASN, RN · May 1, 2007

As I re-read some of the responses I wanted to say one more thing, while their actions are inexcusable and uncondonable I think that in addition to punishing the abusers we need to educate them. I am tired of seeing shaken baby kids where the parents say he just wouldn't stop crying. When I ask them what they tried to get him to stop they just look blankly at me. Situations are often complex and need intervention but locking people in jail in and of itself is not enough we need to prevent these cases rather than just react to them.

Super RT · May 17, 2007

Working in 2 major Trauma centers, I have seen way too many beaten up kids! It seems to be worse at the first of the year and half way through summer break. I just think there are some parents who don't have good coping skills. When my son was little, I couldn't understand why someone could be pushed so far, however when my daughter was a baby, I began to get it. She would scream for hours on end with no break. I knew to put her in her crib, where she couldn't hurt herself and walk outside for 10 minutes. She would still be screaming when I got back, but I was calm again and could be rational. It just seems that the parents of these abused kids are either very young or from financially struggling households. I'm sure that stress can escalate the tendancy toward abuse. The way I have found to deal with the parents is to be polite and calm, but not overly friendly. I don't want to be their best friend, but I always worried that the kids could sense the tension, so I decided to put the kids first and be polite to their families. I am also lucky that my sister is a forensic interviewer working with the kids that survive. I can call her and vent when I get off work, and she can call me to vent. I just remember that I have 2 healthy children at home and that I would seriously maim anyone that hurts them in anyway.