Documentation

Documentation is critically important in obtaining any type of encounter in the ED, but yesterday I had the opportunity to apply what I have learned in the coursework to the fullest. My patient was a fifteen month old who was accompanied by her mother. The child was brought in for head injury. Her behavior was appropriate for a toddler, smiling and interacting with both mom, and me and very active. She was cooperative with the triage. Mom was concerned about the abrasion over her left eye and ecchymotic area under that eye which she stated had happened 2 days prior when the child had fallen off the couch and hit her head on the coffee table. She denied LOC, vomiting or lethargy and stated her activity level had been the usual state. On further exam, I noted a three cm ecchymotic area over the left sphenoid which could be consistent with the fall, but it troubled me that she also had ecchymosis lateral to the right eye, petechial contusions to the inner auricle of the right ear but none on the pinna and also noted pinpoint abrasions to the right occiput. This did not seem consistent with the story. I asked mom about these and she stated that “She is just learning to walk and falls a lot.” A fifteen month old is usually walking fairly well, and running unless developmentally delayed, which she seemed to be bright and happy, so this troubled me. However, since triage was busy and it is not the function of triage to document all findings but just identify them, I marked her as urgent and notated my suspicions of abuse due to the inconsistency. Later, when I got off triage, I took over this patient and got to interact with the police investigator and county child protective worker who had been called. The doctor felt that the findings were consistent with abuse and a report was filed with immediate action taken. I measured all the areas and took photographs and logged them as well as documenting all the individuals and actions we had taken. The child was CT’d which thankfully was negative. The mother had admitted that she had left the child alone with her significant other on a number of occasions. The investigator felt he had enough evidence to make an arrest. The child was released to the custody of the mother and her parents. This story had a happy outcome but I still feel troubled by it. How can a person abuse a sweet innocent toddler? How can the mother allow this? Aside from that, she was so benign about the whole matter and practically lied to me about it in triage. As a mother and patient advocate, this boils my blood. I fear for this child’s safety now and suspect will see more of her in the future. References Lynch, Virginia A. and Duval, Janet Barber. (2006). Forensic Nursing. St. Louis: Elsevier Mosby.

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