• The Toll of Child Neglect, and Worse: Too Little, Too Late

    I am taking a brief hiatus from the snapshots I normally bring you here that play out in our professional and personal lives. Instead, I hope to illuminate a somewhat overlooked and underappreciated opportunity. We as nurse anesthetists can contribute to the welfare of the most vulnerable members of our society: its children.

    Over more than 3 decades of participating in the art and science of safe anesthesia delivery, I have encountered small children in my domestic practice living in challenging social environments and, of those, a subset who clearly were in dire circumstances. During the preoperative assessment we are uniquely placed in an intimate family dynamic with the child as patient and their caregivers, usually mother and father, but it is increasingly common to find other family members or surrogates present. Three children I encountered over the span of my career provide ongoing, sobering, and reflective pause.

    I recall the 2-year-old child with partial-thickness, dime-sized, circular burns on the buttocks and sacrum, several of which had a crosslike pattern centrally located on the burned area. In the privacy of the examination area, created by a wall and 3 pulled curtains, the sole parent confided in me that her “companion” (interestingly she chose that rubric instead of something more identifiable) had used cigarettes and a Phillips-head screwdriver to enforce obedience. When I asked if her pediatrician or any other professional or family member was aware of this, she lowered her gaze and, without showing any other emotion, simply responded with a terse “no.” Standing alone in the room with the child and her mother, I felt an urgency to sweep the child up in my arms and run with her. I don’t know where I envisioned running … just as far away from the woman as possible.

    The second child, a 4-year old, was booked for “dental restoration.” When viewed on the printed operating room schedule, this nomenclature invariably conjures up an image of extensive dental caries in an uncooperative child. When I encountered the patient, sitting in the bed with a doting mom and dad, I was, oddly enough, struck by a paradoxical sense of orchestrated caring. It brought back a painful experience many years ago that I had in my fundamental nursing (RN) program in Colorado during the in-home public health nursing rotation (and where my early interest in epidemiology was catalyzed). This rotation often took me into a world of ostensibly normal parenting, but one that on occasion involved serious neglect. Why the dental restoration child triggered that emotion, to this day I cannot fathom, but it rapidly became clear to me that the negligent oral hygiene in this child was simply one view of a sobering social circumstance. This case involved not only neglect of oral care but also what was discovered on a simple examination to be intentional nutritional impoverishment, trichotillomania (stress-induced pulling out of hair), and bruising on areas of the body (feet, buttocks, and groin) normally covered with clothing. Enquiring about these observations precipitated the “doting” parents to become very defensive, questioning what my role was and threatening to take their child elsewhere. It was not until the dental surgeon and a circulating room nurse arrived did the situation evolve into full disclosure. The parents asked that I be excused from the case, which I complied with.

    The third case is one inextricably wedded to my existential being and continues to unravel me to this day in a way that incites emotional distress from within, in part likely because I had 2 very young children at the time. The child, a 3-year-old, was scheduled for tonsillectomy, adenoidectomy, and ear tubes. The ear, nose, and throat surgeon jovially referred to the patient as “a real problem kid; good luck with induction!” I was soon to realize, as is common among healthcare providers, that the surgeon dealt with her stress using manufactured humor, like trying to put a small adhesive bandage on a gaping wound in hopes of stemming the flow of blood.

    In the brief time I had to meet the patient and her mother, I found a child in diapers who was withdrawn, frightened, and clinging to her. This quite normal behavior was not what got my attention; rather, it was her severely erythematous skin and open sores (“severe diaper rash” as the mother explained) as I watched her being changed. What alerted me was the clear signs of old blood in the perineal area and flecks of new blood on the diaper. A rather direct question posed to the mother elicited a near-decompensating response that her little one, my defenseless patient, had been violated by her boyfriend.

    What was eventually learned in each of these cases was that my observations had not been made—or acted on—by anyone previously. In each of these cases I sought information, documented what was observed, and ensured the immediate involvement of social services, and in the last case, law enforcement. These cases are particularly poignant to me as they serve to remind me of the legal, moral, and otherwise humanitarian mandate that we have to ensure the safety of our pediatric patients.

    Although horrific in obvious ways, these 3 cases, like virtually all things in life, are representative of the far end of a bell-shaped curve. Although thankfully uncommon, cases of suspected or obvious abuse demand our immediate circumspect consideration and action, even when we have concerns that we may be wrong. I’ve certainly had other experiences with cases that, although the thought crossed my mind, did not generate enough amperage for me to go down that path.

    There is little written about the nurse anesthetist’s role as a public health advocate, especially when it comes to child welfare. But, given the unique and extremely intimate relationships that we forge when we encounter a patient (adult or child) and his or her family, we assume a potentially vital perspective in the public health system—one where our roles in nursing and medical advocacy must predominate.

    We all have our stories. I suspect mine is not unique. But, whether you are a newly minted or veteran provider, I hope to remind you that the training, education, and experience that you bring to the healthcare setting extends well beyond your anesthesia care skill set. Encountering a patient whose life is medically challenged is something we are formally prepared to deal with. Encountering a patient who is socially (family, environment) challenged is something I’ve not seen much written about, appears to be absent in most anesthesia curricula, and is not a lecture I’ve seen or heard at a conference.

    The recent Illinois case of the alleged brutal murder by his parents of 5-year-old Andrew “AJ” Freund, who reportedly was subjected to frequent beatings, forced to stand for long periods in a cold shower, and finally beaten to death and buried in a plastic bag represents a catastrophic failure of the social services system.1 System employees had visited the domicile, documenting concerns, concerns that were noted by law enforcement as well. Too little, too late led to this horrific outcome. Physical wounds are not the only ones we may see in our meeting with a patient. More occult, at least in the timeframe and circumstance that define our encounter, are the emotional and mental wounds.

    Act, in a reasoned way, on an encounter that disturbs you or generates concern. Listen to and react to your internal compass. Never be part of a continuum of too little, too late.

    Nota Bene: What to Do If You Suspect Child Abuse or Neglect

    As healthcare providers, we are mandated by law to report suspected child maltreatment. Healthcare institutions and their affiliates all have social services, which is a good starting point, and states have child protective services (CPS), where the care is being delivered. The National Child Abuse Hotline can be reached at all hours, at 1-800-422-4453 (1-800-4-A-CHILD).

    REFERENCE

    1.Miller RW. 5-year-old told doctor of possible abuse before death: “Maybe Mommy didn’t mean to hurt me.” USA Today. April 27, 2019. https://www.usatoday.com/story/news/nation/2019/04/27/aj-freund-missing-boy-crystal-lake-andrew-freund-joann-cunningham/3598511002/ Accessed May 1, 2019.

    Please click here for a PDF of this article.


    To the editor: My eyes filled with tears as I read the Editor’s Desk article in the June 2019 edition of AANA Journal. Dr Biddle’s essay on child abuse and neglect was not only a service to our profession, it hit home to me on a close personal level. My great-grandson, Jackson James (JJ) Newman was abused by his father and died as a result in February of this year. The autopsy showed blunt force trauma to the head, body, malnutrition, and methamphetamine in his bloodstream. JJ was only 2 years old, a bright, active, and happy child. There was a major system breakdown in Las Vegas where they lived. Child Protective Services and the police ignored our calls for welfare checks and parental and grandparent rights. There has finally been an arrest and charges are pending, but nothing will bring back our precious baby. I am begging all CRNAs and SRNAs to read Dr Biddle’s essay and to be alert to signs of child abuse and report it. To quote the essay, “Never be part of the continuum of too little, too late.”

    Mary Jeanette Mannino, JD, CRNA AANA Former President, 1987-88 Laguna Niguel, California

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