Webinar presenters Dyanne Greer and Roger Blevins answered a number of your questions after their presentation, “Abusive Head Trauma Part 2.” Here are a few of their responses.
Audience Question: You talked about the importance of Vitamin K in newborns. Can you repeat what is Vitamin K again and what does it do?
Roger Blevins: Vitamin K is a vitamin which doesn’t cross over from mom to baby very well and the baby does not have a lot of it. It is critical in clotting so you have to have enough Vitamin K to clot. This is why these days in the U.S., back since the ’60s actually, babies have gotten an injection of Vitamin K because they don’t have enough and they’re not going to develop it for a few weeks. If they run significantly low on Vitamin K, they can have big bad bleeding problems including spontaneous head bleeds and this is why it’s important to know about Vitamin K.
Audience Question: Next question, this might be in another webinar entirely you used the phrase, what is fatal belly injury?
Roger Blevins: That was me using layman’s terminology. The child, the kids frequently get an abdominal injury, sometimes multi-organ abdominal injury without any external signs of trauma, so the child can have lacerations or actually what we call fractures of the liver. They can have an injury to the spleen, they can have an injury to the pancreas. They can also have an injury to what we call a viscous organ like the stomach or the gut. The bad news with that type of injury is you got a hole that’s opened up in the gut usually from kicking or punching. What would occur is the kid won’t act terribly sick immediately and the younger they are the less specific their symptoms are. They may even want to eat. They may act fairly normal for many many hours, sometimes 24 to 48 hours. During that period of time, the gut bacteria is released into the abdominal cavity the peritoneum, and it sets up a really intense infection. Often when the kids have that, they will have it in the bloodstream. By the time you get to them and you won’t be able to save them. Kids will get fatal belly injury with no external signs of trauma and it may not show up for a day or so. That’s why we’re really careful in these kids to evaluate them well and watch them carefully.
Audience Question: Is abusive head trauma just a child-oriented diagnosis or can it happen throughout the lifespan? For example, could it show up with an elder abuse case?
Roger Blevins: It could. Sure. Things will be different with an elder abuse case because elderly people tend to have atrophy or some shrinking of the brain and those folks are much more likely to get a subdural or subarachnoid hemorrhage with an accidental fall, something like that because there’s an increased distance from the skull to the brain, the blood vessels have to bridge that and it’s easier to tear them. So you can get abusive head trauma in an elderly person but it’s a different diagnostic feature.
Audience Question: What do you recommend if the family refuses to share their medical history? What can the investigator do?
Dyanne Greer: Well, I would document the fact that the family is not cooperative. Then you can find out who their insurance company is. We’ve gotten GJ subpoenas to find out where they were treated, and in these cases, there is a HIPAA exception, and state laws may also come into play. There isn’t any confidentiality in child abuse cases, so the investigator can get these records. The insurance company should have every place the child has received care. The front sheet of the medical record that gives pertinent information usually included the insurance company, so you need to be sure you get this sheet in the records you get from the hospital. You can also start by starting your interview with “we’re just trying to figure out what is going on with the child”, which is less threatening to parents. Don’t make the initial interaction with the caretaker a confrontational one; make it that you’re trying to work with them to find out what’s going on with their baby. The information you get from doctors is certainly important, as a normal parent would want to get the child the best treatment. In order to do that, doctors need an accurate history. Obviously, if the parents are refusing to give this information, we as prosecutors can use that down the road saying “they weren’t willing to give this important information to the doctors”. This is highly suspicious because most parents would do anything to make sure their child gets the best medical treatment.
Roger Blevins: When I go in to get a medical history from a caregiver, particularly, the parents, I will come right out and say, “You know, we need this information to treat your baby and I need this information so that I can help you figure out what may have happened to this youngster.” And I will simply tell parents, ” I don’t walk around all day long diagnosing child abuse. That’s no fun.” What I like to do– and this is absolutely true– what I like to do is find an innocent answer for the child’s health problem because then you’re everybody’s hero. And it’s medically very interesting.
Audience Question: So Dyanne you might have answered this question but I’m gonna go ahead and bring this one up. As a law enforcement officer, must I get a warrant to be able to view the medical records?
Dyanne Greer: No, and again that’s what we’ve said. On these cases, you should not have to. Under HIPPA there is an exception, I believe it’s CFR 42 163.312 (Code of Federal Regulations.). There is an exception for both child protective services and law enforcement to be able to get medical records in a child abuse case and take a look at your state law because your child abuse statute should have that also in there. We do not need parental permission to get these. If you do, talk to the legal department of the hospital because a lot of times they may or may not be aware of it. If you have smaller hospitals and you have a private practitioner who may not be aware of that but you shouldn’t need to, obviously, if you got somebody who’s not gonna do it then I would just get a grand jury subpoena which under HIPPA is allowed.
Audience Question: Is there a way for radiologists to determine the age of fractures?
Roger Blevins: If you’re a child radiologist or pediatric radiologist and you are really really good at aging fractures, you might. But generally, that’s not something that your average radiologist would get in to. At least not in court.
Dyanne Greer: And again in most of these, aging is a big problem in these cases for us prosecutors and medical investigators because they’re estimates. This is why when you talk to doctors, you talk to them about a subdural, “Doc how old is the subdural?” They will give you a range because it depends on a lot of different things.
What I prefer you to do is not to ask the age; instead ask “Given the child’s condition, what symptoms would you expect to see? How soon would they show up?” Symptoms and symptomatology are a much better gauge of when things happen than asking in hours, minutes and days. Doctors often have different ideas of what is acute, subacute and chronic.
Roger Blevins: Medically, we generally will not try to go there as far as trying to implicate a caregiver particularly when the kid has been under the care of several people or two or three people during the day.
Audience Question: You talked earlier about how the parent or the caregiver will call their mother, call their grandmother, call their girlfriend, etc. asking for help. Everybody but 911. The question is as an LEO, do I need to get a warrant to get custody of the cellphone and I’m gonna jump in here also Internet search history etc. could check for the messages and the site search etc.?
Dyanne Greer: I would say first you need to talk to prosecutors in your jurisdiction. But generally, if you have someone saying “I texted my mom,” and you think that’s relevant, I think at that point you can seize the phone to make sure it doesn’t get erased, but you are going to need to get a warrant to get into the phone. So as you’re talking to your suspect or parents or caretaker, get them to talk about what they did on the phone? Did you text anyone? Did you google anything? If so, that is the basis for getting into the phone history. Talk to your prosecutors as different jurisdictions will handle this differently.