Abuse is a difficult topic that all healthcare professional must learn to recognize and understand. The topic is difficult in that no two abuse cases are the same, and each has to be dealt with uniquely. Furthermore, the question arises, ‘is there actually abuse taking place?’. In this particular case study; a father, patient D, has brought his mother, patient G and his son, Patient B to the emergency room after a car accident.
The nurse in triage saw the patients first and is suspicious of the father. She states he has alcohol on his breath and this mother and son have bruising at different stages of healing over there face, arms and legs. After getting x-rays of all three patients, the radiologist informs the student physician assistant that patients B & G’s x-rays show evidence of previous fracture, correlating to possible child and elderly abuse. Each of these patient perspectives and the student Physician Assistant will be discussed.
Child abuse, as defined by the Center for Disease Control (2018) is ‘any act or series of commission or omission by a parent or other caregiver that results in harm, potential for harm or threat of the harm to a child’ (Center for Disease Control, 2018). Patient B is a 7-year-old boy, who appears in pain, and scared. Talking with him you find out that he is in the 2nd grade and has been dealing with a bully at school.
Bullying is a very common problem that young school-age children, with more than 1 out of 5 students reported being bullied in a study cited from the PACER’s National Bullying Prevention Center (PACER’s, 2018) The bully was a 5th grader that has been bullying the patient for multiple months. At first, he was afraid to tell his parents or his teacher.
In one study cited by the U.S. Department of Health and Human Services, only 20-30% of students who are bullied notify adults about the bullying’ (U.S. Department of Health and Human Services, 2017). Then one day, the bully pushed him off a playscape during recess, resulting in a broken wrist and multiple bruises. Once Patient B’s teacher saw this and reported it to the school and his parent’s, the bully was expelled from school. The little boy doesn’t want to leave his father, as he is scared from the accident and in lots of pain.
The signs of bullying and the signs of abuse are identical. The National Centre Against Bullying (2018) says changes in sleep patterns, becoming withdrawn, has unexplained bruises, cuts, scratches, not wanting to go to school are some of the common signs of bullying (National Centre Against Bullying, 2018). The Mayo Clinic says changes in behaviors, becoming withdrawn, unexplained injuries, bruises, fractures or burns, and frequent school absences are also sign of abuse (Mayo Clinic, 2018). Taking a good history will help providers differentiate between the two.
Elderly abuse as defined by the Florida Department of Children and Families is ‘any willful act or threatened act by a relative, caregiver, or household member which causes or is likely to cause significant impairment to a vulnerable adult’s physical, mental or emotional health’ (Florida Department of Children and Families (Florida Department of Children and Families, 2018). Some physical indicators of abuse in the elderly include unexplained fractures, lacerations, burns, scars, balding spots, and constant pain (Florida Department of Children and Families, 2018).
With patient G only speaking Spanish, the first obstacle to overcome is communication. To best communicate with this patient a translator who is not the patient’s family is necessary. Once with the translator, patient G tells her story. Until recently Pt. G was living alone at home, where are caregiver would come help take care of her. This arrangement started off wonderfully, as the caregiver attended to all of her needs.
However, one day the caregiver came and was in a terrible mood. When she asked him, what had him so down, he began yelling at her, telling her to mind her own business. As he continued to care for her, his patience faded, and anger grew. With her already declining health from cancer, she couldn’t do as much, and he began hitting her. After two months, her son walked in on this abuse, when he surprised her with a dinner.
The caregiver was arrested, but she was in no way able to take care of herself alone. Her son graciously offered to have her move in with him, and he would help take care of her with his wife and children. Patient G states, ‘My life was starting to turn around until this accident. The car that hit us, blew this light and slammed right into the passenger side directly hitting me and my grandson. I am just thankful we are all alive!’
Patient D is the father of Patient B and son of Patient G. He is approximately 160 lbs, 5’8”, and appears shaken and worried. It would be easy to start interviewing the father with the preconceived notion that he is the abuser. However, doing so will cloud better judgment and understanding of his perspective. Patient B states, ‘things have been rough for my family lately, my mother was being abused by a caregiver, that I hired, thinking he was a perfect match.
My son was being bullied at school and no one knew until his wrist was broken at recess. With my mother moving in and trying to care for her, and my wife travels a lot of work, my stress has been through the roof. By the grace of God, I was just given a promotion at work. To celebrate this good break, I took my mother and son out for dinner. I celebrated with just two drinks.
I didn’t feel any effects of the drinks. We were on our way back home when this driver blew through his red light and slammed into my passenger side. I only wish he had hit my side instead of my mother and son’s side! Now that we are here, and I am seeing the looks of disgust from the staff, I already can tell they think this is my fault and must think I am some kind of monster. Hopefully, you at least believe me’.
Physician Assistant Student, PA-S
As the PA-S abuse is a major concern when presented with a case of this nature. Initially, it is easy to jump to the conclusion that the father is abusive to his mother and his son and is an alcoholic. In addition to the x-rays of each patient’s right hand and wrist, a blood alcohol test of the father should be taken, as well as a urine drug screen. Assuming patient D was telling the truth, the blood alcohol level should be less than 0.08, which is an illegal level of intoxication to drive a motor vehicle (Stim, R., 2018). Given his history, you would suspect a blood alcohol content around 0.04 (Stim, R., 2018). Should the father have had these drinks, knowing that he was the one driving that night? No, he should not have, although assuming he is telling the truth, he has not broken the law.
For patient B, a comparison to any old x-rays would help clarify if there is any continued abuse onto the child since his bully was expelled from school.
Patient G displays many of the common physical indicators of abuse, however, they could be explained by her history of abusive caregiver, cancer diagnosis and the more recent motor vehicle accident. Looking at her medical history could potentially help set the background of her story. Has she recently undergone any treatment for her cancer, like chemo and radiation? What have her most recent labs looked like and is there any drastic difference? The PA-S should also look into any previous x-rays if any from when she was abused by her form caregiver. It takes a properly trained PA-S, to take a step back and fully incorporate all the patient’s perspectives in making their decision to report suspected abuse. In the end, reporting this to the Florida Department of Children and Families would be appropriate, as this case does have many indicators of abuse.
It is mandatory for all healthcare workers to report any suspected abuse to the appropriate personnel. In this case, although the patient’s stories do align, and could explain the presentation, calling the appropriate authorities is necessary. Even if no abuse is found, the caseworkers may be able to offer aid to this family to help the son cope with his recent bullying, and help the father take care of his sick mother. Understandably, this family may be hesitant about calling in additional help given their history, but it would greatly benefit this family. Recognizing common signs of abuse and taking a good history will help aid any healthcare worker in identifying abuse and getting their patients the help, they need to live a happier and healthier life.
- Center for Disease Control. (2018). Definitions|Child Abuse and Neglect|Violence Prevention|Injury Center|CDC. Retrieved from https://www.cdc.gov/violenceprevention/childabuseandneglect/definitions.html
- Florida Department of Children and Families. (2014). What is elder abuse?. Retrieved from http://www.myflfamilies.com/service-programs/adult-protective-services/what-is-adult-abuse
- Mayo Clinic. (2018). Child abuse – Symptoms and causes. Retrieved from https://www.mayoclinic.org/diseases-conditions/child-abuse/symptoms-causes/syc-20370864
- National Centre Against Bullying. (2018). Signs Of Bullying. Retrieved from https://www.ncab.org.au/bullying-advice/bullying-for-parents/signs-of-bullying/
- PACER’s National Bullying Prevention Center. (2017). Bullying Statistics. Retrieved from https://www.pacer.org/bullying/resources/stats.asp
- Stim, R. (2018). Blood Alcohol Level Chart: Are You Too Drunk to Legally Drive?. Retrieved from https://dui.drivinglaws.org/drink-table.php
- U.S. Department of Health and Human Services. (2017). Facts About Bullying. Retrieved from https://www.stopbullying.gov/media/facts/index.html#ftn13