Marks related to cultural practices (Cupping, Cao Gao)
Pigmented or blue nevi
Father of Gang-Tattooed Child Arrested Boy was restrained during painful process: police By JESSICA GREENE Updated 9:58 AM PDT, Fri, May 15, 2009 Related Topics: Fresno | Crime | Gan g Violenc e 16 Commen ts Post a Comment PRINT EMAIL Fresno PD Fr esno police re leased this picture of the boy's tattoed hip area. The law finally caught up with an alleged gang member who police say held down his 7-year-old son while a fellow gang-banger tattooed the boy's belly with the group's insignia. Enlarge Photo Police say 26-year-old Enrique Gonzales held down his 7-year-old son while another gang member tattoed the group's insignia on his belly. Fresno cops arrested Enrique Gonzalez , 26, at hotel in the S ierra foothills and booked him for investig ation of mayhem, child abuse, false imprisonment, battery, participating in a criminal street gang and committing a crime for the benefit of a gang, Police Chief Jerry Dyer said. Gonzales, a member of Fresno's largest street gang, the Bulldogs, held down his son while another gang member painfully marked the boy's belly with the group's insignia -- a paw print, police said. The boy's mother reported the incident in April, police said. When police searched the hotel room where they arrested Gonzales, they found a picture of him and the boy, along with another child who also had gang graffiti on their bodies, the Fresno Bee reported . Related Stories • 7-Year-Old Held Down for Gang Tatt: Police The alleged tattooer, 20-year-old Travis Gorman , was arrested not long after the incident and charged with six felonies. H e pleaded not guilty last month and is being held under a $700,000 bond. Famil y members tol d police the boy is traumatized by the incident. Copyright Associated Press / NBC Bay Area
Dating of Bruises
What causes the color change in a bruise?
Why do we care about dating bruises?
What factors affect the appearance of a bruise?
Chronicity of bruising
Blows that cause internal injury without external signs
Symmetric or mirrored marks
Physician Accuracy in Dating Bruises
Emergency pediatricians’ accuracy within 24 hours of actual age: 47.6%
Other physicians’ accuracy: 29.4%
Trainees’ accuracy: 36.8%
Factors used to estimate age
Langlois and Gresham (1991)
Bruise with any yellow is older than 18 hours
Red, blue, purple, black may occur any time from 1 hour after bruising to resolution
Red has no bearing on the age of the bruise, because red is present in all bruises
Bruises of identical age and cause on the same person may not appear as the same color and may not change at the same rate
New Technology in Bruise Dating
Burns in Child Abuse
Burns comprise 10% of all severe child abuse
Inflicted burns comprise up to 25% of severe burns
Child abuse burn victims are younger and have longer hospital stays and higher mortality rates
Burn victims are almost always <10 years; majority <2 years
80% of deliberately inflicted burns are not associated with other trauma
Time to Burn by Water Temperature in Adults from Moritz AR and Henriques FC. Studies of thermal injury. Am J Pathol. 1947; 23:695-720 Degrees Centigrade Degrees Fahrenheit Time (Seconds) 65 149 1 60 140 2 55 131 12 50 122 120 45 113 10800
Scalding: Spill Burn
Where were caretakers at the time of the accident?
How many persons were home at the time?
How tall is the child?
What is the child’s developmental level?
How much liquid was in the pan?
Does the child habitually play in the kitchen?
Scald burns with sharp margins vs. splash pattern
Uniform intensity of burn
“Doughnut” shape on buttocks--central sparing
Burn ends at wrist
Entire hand involved
Back of hand likely in contact longest
Accident in Afghanistan?
Scalded skin syndrome
Scalded Skin Syndrome
Staphylococcal Scalded Skin
Would You Miss a Ruptured Ectopic?
Know the risk factors
Would You Miss A Pulmonary Embolism?
Do a good exam
Would You Miss an Acute MI?
Ask questions in the right way
Why do we not put child abuse in the same category as other potentially lethal processes?
We can’t empathize? We empathize too much with caregivers?
It’s too much work?
We don’t have well-established criteria?
The victims don’t sue us?
“Physicians are nice people.”
Child Abuse Can be Fatal, Too
Keep your index of suspicion high
Keep history and exam consistent with suspicion
Use any and all resources necessary
Any child can be the victim of maltreatment
A large percentage of serious or fatal maltreatment occurs on the background of a previous missed abusive incident
Child abuse is 5X more common in families with DV
RED FLAGS: Risk factors, poor growth, behavior changes, recurrent injuries, patterns of injury consistent with abuse