Who you are:
You are an FY2 in PediatricsWho the patient is:
Mrs Maria Jones bought her 2-month-old son, Michael Smith, with swelling in his left arm. X-ray was done and spiral fracture has been diagnosed. (She also comes with 3-year-old son)What you should do:
Talk to the mother and address the initial management plan with her
Station Flow:
- Mother is a nurse and while she came back from the night shift, she noticed the swelling.
- Her boyfriend usually takes care of her child. Before the night shift, her son was fine.
- Her boyfriend is not the son’s biological father. Spiral fracture is caused by deliberately twisting.
- That is why we are suspecting NAI.
Data Gathering
Introduction
Q: Hello, I’m Dr (last name). I am one of the doctors in this Pediatrics Department.
Q: Am I talking to the mother of Michael? - Yes, Doctor. I’m Maria.
Q: Okay Maria, can you please confirm your son’s name and age? - Michael Smith, 2-months old
Q: I can see from my notes that you’ve just brought in your son because he has some swelling in his arm. Can you tell me more about that?
Explore incident history.
Q: When did you notice? - this morning when I got back from my night shift
Q: What did you see?
Q: Was he fine last night?
Q: Who takes care of him from last night to this morning? - my boyfriend
Q: Who usually takes care of your child especially when you are away? - My boyfriend
Q: What does he say about this situation? - He said h e fell down from the sofa
Q: When did you bring your child to the hospital?
Q: Have you asked him about the child? - No
Q: Is there anyone else at home?
Q: Did he attend any nursery?
Q: Do you have any other children?
Q: Any other injury that you’ve noticed apart from this?
Explore about the child.
Q: How was the pregnancy? Was it a planned pregnancy?
Q: How was the delivery? Any complications?
Q: Do you think your child is generally fit & well?
Q: Any congenital/medical illness?
Q: Has this ever happened before?
Q: Is he taking any regular medications?
Q: Any allergies?
Q: How is he doing now? Is he active & playful?
Explore about home environment.
Q: Who does Michael live with other than you? - My boyfriend, Tom
Q: Is he Michael’s biological father? - No
Q: How are things at home? How is the relationship between you and your boyfriend? How is the relationship between your son & your boyfriend? - I think they get on well so far.
Explore about the partner.
Q: How long have you been in this relationship?
Q: What does he do for a living?
Q: Has he ever been aggressive towards the child?
Q: Does he drink alcohol or use recreational drugs?
Examination:
If it has already been done, you do not need to do another physical examination.
Management:
Explain the injury:
- After our assessment & from x-ray findings, we found that your son has a fracture in his arm.
- This type of fracture is not something that occurs spontaneously. In order for this to happen, a huge force is applied to the arm or fall from height.
Do you have any idea about that? - No
P: Do you mean that my boyfriend did this?
Q: We are not accusing anyone in particular but according to you, you left your child with your boyfriend & he was fine. Therefore, we have reasons to believe your boyfriend could have done this. I’m sorry to ask this out but could there be any chance that he might have harmed the child?
P: No
Q: Sometimes, children can be difficult to look after. This can lead to parents mishandled the child? Has this been the case with you? - No, how could I?
Q: Well, it might be something that we’ve not found out about yet. But there are a few things we can do in this case. Would you like to hear about that?
Q: First of all, we will be keep Michael in the hospital for a while and do a few more tests such as a skeletal survey, eye examination & CT scan of the head if necessary. We will refer him to the bone specialist to stabilize this fracture. In the meanwhile, we will also be prescribing painkillers for him. How does that sound?
Q: I will also need to involve my seniors as well. After that we will refer your son to child protective services/safeguarding team and social services? - Why? - When we’re in a situation like this, we need to refer because we have concerns that this may happen again.
- Will they take my child away? - That’s not the 1st thing they will do. They will first speak to you and see how they can help you to look after your child. Taking children from parents will be the last option for them. So, don’t worry too much about it.
- Why can ’ t I see the child till now? - Maybe he is being assessed by our colleagues. You should be able to see him soon.
- Why are you admitting him ? - We have to further assess him & treat him and to keep him safe as well.
- Do you think I am a bad mom? - I’m so sorry if I gave you that impression. You have done what you could to help him.