My youngest daughter, Laura, is studying for a degree in psychology. She wants to be a counselor for troubled youth. Earlier in her college days, she enjoyed serving as a mentor for an adolescent girl who had been sexually abused. This girl had thankfully been removed from her damaging environment and was adjusting to foster care, and Laura met with her weekly to talk and get ice cream.
Laura has been given an amazing opportunity to work as a mental health technician in a home for children who have been victimized and are too disturbed to enter the local foster care system. This center will provide her with four weeks of paid training — which sounds wonderful to me, but very scary to her. I have tried to convince my daughter that they will teach her appropriate techniques to use in managing and helping psychologically and physically injured children.
She recently asked me and my husband how we ever got used to seeing the effects of child abuse, hearing those tragic stories, and interacting with the parents or family members who injured the child. My husband is a retired pediatric nephrologist, and I am a retired neonatologist. We both experienced excellent pediatric residency training in large city-county hospital systems in which we saw everything, including horrific child abuse cases.
We told Laura that you can care deeply about the kids who are injured, and care for them medically, but you cannot let yourself become so shocked or disturbed as to be nonfunctional in providing their care. We told her that we learned to harden ourselves in those situations and to provide safety and medical care for the child. The busyness and necessity of getting the medical things done were great distractions.
Our daughter is a highly empathetic and sensitive person who fears that she might feel the child’s pain too deeply to be able to care for them. She is anxious that she will be incapacitated by the horror of what she might see or hear about the children she will care for.
We each shared with her our first experience of encountering severe child abuse and finding ourselves capable of dealing professionally with each dreadful case:
I was an intern in the Parkland General Hospital pediatric emergency room in Dallas, Texas, when I was confronted with a four-year-old girl who was obtunded and had scalded hands and feet. Her severe burns were in the pattern of stockings-and-gloves burn from being dunked into boiling hot bath water. She had old and new cigarette burns scattered over her tiny body and bruises in various sizes and stages. Her mother originally told me that she fell off the couch.
While I stabilized this child and carefully noted all her injuries in my History and Physical exam (even drawing pictures), I seethed with anger at what lay before me. The child clearly had been severely abused. We stabilized her and transferred her to the pediatric intensive care unit (PICU) at Dallas Children’s Hospital where she underwent heroic intensive care and support until her death four days later from a massive cerebral hemorrhage. Her head trauma most likely resulted from her being battered against a wall.
After the child was transferred to the PICU, I went back to pressure the mother into giving me a more accurate history. When I pleaded with the mother to tell the truth, she finally, and tearfully, confessed that her boyfriend had been hurting her daughter. Afterwards, I walked over to the Pediatric ICU and added that statement into my original note, hoping that someone would notice and turn him in to the authorities. Of course, seeing this darling little girl so injured made everyone around the child just sick at the possibility of such severe physical abuse. Witnessing that kind of brutal and senseless abuse can be nauseating.
Three years later, while I was in my neonatology fellowship training, I gladly accepted the opportunity to testify against the man who injured that child. In fact, he had been arrested and charged with murder after the child died. After much delay, his trial was scheduled to take place and I was subpoenaed to testify.
While in court on the witness stand, I eagerly answered questions about how the girl had presented and was able to use my extensive handwritten note and pictures to review her physical findings and to recount what the mother had told me. I enjoyed glaring at the defendant once I had completed my descriptions of her physical findings to the jury. I especially relished hearing from the district attorney, some days later, that the man was convicted of murder and sentenced to life imprisonment. His guilty verdict would not bring that child back, but I was happy that he got what he deserved.
My husband told our daughter the story of his experience as an intern, when he admitted a two-year-old child in a coma to the PICU at Texas Children’s Hospital in Houston, Texas. Astonishingly, this was not her first admission with coma. She had previously been admitted with coma two times before! Thankfully, after each of these previous admissions to the PICU with a coma, she recovered.
My husband related her presentation with vomiting, muscle weakness, seizures, and obtundation which progressed into a coma. Unfortunately, this time, while he was one of her doctors, her neurological instability could not be reversed by the PICU staff and pediatric neurologists. Not only could they not save her, but they were unable to determine the cause of her coma. This beautiful toddler died in a coma of unknown etiology.
Of course, all the residents and staff felt miserable that they could neither bring her around, nor ascertain the cause of her repeated admissions for coma. Her death created a shared and defeating jumble of sadness and loss for the whole team. It is tragic when you lose a patient, when you are unable to save them, but it is even worse when you cannot determine why they died.
Months later, in another city in Texas, a general pediatrician cared for the sibling of the child who had died at Texas Children’s Hospital. Her younger sister was admitted to his hospital with coma of unknown origin after presenting with vomiting, muscle weakness, and seizures. Happily, this child recovered.
Soon thereafter, the perplexed and thoughtful pediatrician attended a national meeting of the American Academy of Pediatrics in another city. This is a meeting of expert instructors who provide continuing medical education. During the break in between meetings, the pediatrician chanced to meet with a pharmacologist and described to him how his little patient, the second sibling, had presented. The pharmacologist opined that the child could have been poisoned by ergotamine, a medication that is given for migraines.
The next time the child presented to the PICU with coma, the pediatrician made sure that serum and urine drug toxicology panels were obtained and that they included ergotamine. It turned out that the child had been poisoned with ergotamine! This was a medication that the mother was supposedly taking for her migraines. Afterwards, the mother was arrested for child abuse and charged with attempted murder. The pediatrician called the PICU doctors in Houston to share the news of his uncovering the probable etiology of the coma that each girl had suffered through.
This was a case of Munchhausen’s by proxy (now called factitious disorder) in which a caregiver, usually the mother, who is mentally unstable, attempts to sicken her child by any means — in these cases with medication overdose and poisoning — to bring attention to herself. It is a rare and severe form of maternal mental illness, one in which a mother intentionally sickens and harms her own child.
Our daughter listened to these stories from our early days in training and could not imagine how we were able to persevere in those cases. We told her that you do what you can, what you are trained to do, and you always try to help and protect the injured child. You control your emotions while you are doing the actual work, and then deal with your feelings later when you can process the horrible thing that you have seen executed on a child.
We reassured Laura that she would be able to do this, too. She would learn to harden herself to witness the incredible offense that is child abuse. She would learn to do what she could to comfort and care for those abused children, and deal with her feelings, too.