Doctors in Dependency Cases - Children's Advocacy Institute
Doctors in Dependency Cases Use of an Expert Definition Anyone who knows more than I do Artificial Intelligance There to provide information There to educate Not there to advocate
Doctors Medical Education Four years US schools vs. non US schools Internship Become licensed after passing Part 3 of Medical Board Residency
Variable length of training Orthopedic Surgery 5 years Fellowship additional training Doctors Board certification Not one national certifying board American Board of Medical Specialties
Continuing Medical Education Re-certification Maintenance of Certification Doctors in Dependency Cases What they are: Interpreters of the medical facts Trained Observers Schooled in Science, not law What could have happened, not what more probably
than not did happen Medical Opinion Defined by the basis for that opinion Basis means facts / observations / interpretation of data Doctors in Dependency Cases What they are Not: Triers of fact
Knowledgeable of legal terms Able to take sides Bias does not apply to data Able to extend opinion beyond set of facts Easy to deal with Utilizing Doctors in Dependency Cases
How Doctors can Help Identify / describe patterns of injury Fractures, burns, bruises, retinal hemorrhaging Assemble a Timeline of injuries Need serial data points to be most specific Did injuries occur at the same time Using information from multiple sources Put history of injury into context
Could the injuries have occurred as described? Pointing out what doesnt fit equally as important as corroborating history Putting Patterns into Context Childs age / weight Pediatrician charts important Metabolic status Catabolic vs. Anabolic state
Congenital anomalies Clavicle, tibia congenital non-unions Inheritable diseases Osteogenesis Imperfecta Birth related issues Small for gestational weight Neonatal Ricketts
Collecting the Data Primary Survey Collect data from first ER contact Records, Lab, X-rays / Images, scans Consultations
Ophthalmology Neurology Neurosurgery Orthopedic Surgery Hematology Plastic Surgery (Burns)
Collecting the Data Secondary Survey Repeat Skeletal Survey at 2 weeks MRI Bone Scan Operative Reports Follow up consultations OES 900 exams Patient Siblings
What Helps / What Doesnt Helpful Petition included Scans on CD include all studies Head CT need bone windows Expert Opinion reports If less than 3 months old Birth Records
What Helps / What Doesnt Not as Useful Police reports Live Scans Prior NAT reports / allegations Social worker interviews with treating doctors Sibling medical records Utilizing Experts
Report the facts Facts form basis of Opinions Differentiate actual from possible Secondary data key Establish Timelines of Injury Clues to aging of injuries Callus formation long bones Soft Tissue Swelling skull fractures Bruise patterns of healing
Purple to red to yellow / green Utilizing Experts Identifying patterns of injury SDH, retinal hemorrhaging, MCFs, posterior rib fractures Explain Pathophysiology of Injuries Spiral fracture Transverse fracture Oblique fracture
Tool marks Burns Bruise / hematoma / hemorrhage Utilizing Experts Interpreting Reports What data was used for the basis of the opinion(s) When was the report prepared Pre-secondary survey
How was the data obtained First hand vs. second hand Did they actually review the films independent of another expert or not Primary source verification Differentiating Experts Sub Specialty Radiologist vs. Orthopedic Surgeon
Experience / Education What was reviewed Primary source verification Reliance on records / consultations Verify with secondary survey Utilizing Experts Building a case Series of opinions based upon interpretation of data sets
Pre Trial Opinion letters What was reviewed Opinions Basis for those opinions If left untreated Disfigurement, Dysfunction, Deformity Death
Utilizing Experts Trial Testimony Never a surprise Explain opinions / basis for opinions Never biased or judgmental Never combative Use props as necessary to make a point Posterior rib fractures Explaining x-rays / scans helpful to demonstrate
depth of knowledge / understanding Common Myths and the Truth Myths Certain injuries are classic for non accidental trauma Patterns can be characteristic of NAT Individual injuries are rarely characteristic
Need to understand Classic or path gnomonic signs of abuse Classic Fractures Non-Accidental Trauma Metaphyseal Corner Fractures Distal femur / Proximal tibia Rib fractures
Bilateral, posterior paraspinal Ribs 4 to 9 most common 4 or greater high risk of death Spiral Fractures Humerus / Femur Distal part of spiral points to direction of twist Skull Fractures
Parietal most common Epidural hematoma vas subdural hematoma Classic Fractures Non-Accidental Trauma Metaphyseal Corner Fractures Classic metaphyseal lesion End of the bone Adjacent to the growth plate
Described by PK Kleiman, MD 1986 article Significant debate about callus formation Up to 1/3 no callus Classic Fractures Non-Accidental Trauma Rib fractures Posterior versus lateral Squeeze versus direct trauma
Anterior posterior force versus lateral compression Clavicles are protected May be very hard to see initially Usually picked up in the healing phase 4 or more are associates with significant chance of death Classic Fractures
Non-Accidental Trauma Spiral fractures Fracture morphology is related to how the force is applied Transverse fractures are bending moments of force Spiral fractures are rotational moments of force Oblique fractures are a combination of the two
Classic Fractures Non-Accidental Trauma Skull fractures Heaviest part of a baby Parietal fracture is most common too many lines sign Have to differentiate from normal skull sutures Overlying hematoma is best way to date fracture
Galeal fascia (scalp) overlies the skull Swelling maximal in 24 to 48 hours, gone in 5 to 7 days Look for tool marks Brain Hematomas Three layers of the brain Dura Mater Thick outer covering Arachnoid Mater
Thin spidery layer Lots of blood vessels Can have spontaneous hemorrhage Pia Mater Thinnest layer Most Delicate Brain Hematomas
Epidural Hematoma Outside the dura, beneath the skull Frequently associated with skull fractures (parietal) Common with being dropped
Outside in trauma Subdural hematoma Beneath the dura
May become Hygroma (fluid tumor) Associated with acceleration / deceleration May be acute or chronic May be caused by meningitis Intra-parenchymal bleed Within the brain Causes scarring / long term lesions
Shaken Baby Syndrome Association of Shaking / Squeezing Subdural hematoma Retinal Hemorrhages Other etiologies meningitis, CPR Symmetric posterior Rib fractures Associated with Metaphyseal Corner Fractures
Blunt abdominal trauma Look for elevated enzymes Specific pathologic entity first described in 1972 60% involve boys Most common under 1 year of age Need to rule out bleeding disorder Factor XII, Factor VIII
Extension pattern, transverse Forearm mid-shaft fractures May be occult Both bones always involved Cross Examination Tips Cross Examination Tips Obtain pre trial reports and have them
reviewed for accuracy Identify opinions based on primary source verification versus reliance on other sources Understand the basis for opinions at time of trial Expose gaps in theories In x-ray reports look to the findings section versus the conclusion section
Cross Examination Tips Use checklist to make sure all available data is present Make sure secondary skeletal surveys were done If not, why? Use hypothetical to make points If rib fractures are subtle Was bone scan done?
Metaphyseal Corner Fractures Can be confirmed by MRI Cross Examination Tips Do not dwell on interpretation opinion Attack basis for that opinion If the basis is false, opinion is not as strong Focus on whole picture Identify and analyze patterns or specifically lack of
patterns of abuse Rare that one injury denotes a pattern Fracture 101 Fracture Healing Bone is Alive Blood Supply from both intra-medullary and periosteal sources
Age determines metabolic rate The younger the patient, the faster the process Consistent healing Pattern Stages of healing Acute versus chronic Allow aging of the fracture pattern Fracture Healing Acute fracture
May or may not swell Early Callous Formation Appears at 5 to 7 days Mature Callus Fracture line disappears at about 4 weeks Re-modeling May take years
The younger, the better Bone 101 Children Grow through growth plates on the end of the bone Tube of tooth paste Fractures remodel best at the ends of the bone Angular deformities correct in the plane of the
joint Bruises Caused by hemorrhage into the skin Small vessels rupture Can be caused by anything disrupting those vessels Petechiae small punctate hemorrhages May be caused by emboli
Can occur in internal organs Thymus gland in the neck Bruises Resolve by reabsorbtion Blood products brake down Porphyrins Blood pigments Blue to red to green to yellow
Able to date loosely by color Depends on metabolic status Depends on nutrition Retinal Hemorrhages Key link www.cincinnatichildrens.org/svc/alpha/c/childabuse/tools/retinal-hemorrhage.htm Bleeding involving small vessels at back of the
retina Caused by increase / decrease in presure Can be unilateral Associated with traumatic brain injury Retinal Hemorrhages Can it be associated with accidental injury? Case reports of 3 children with household trauma Localized to the posterior pole
215 children 2 with hemorrhages Both in MVAs Can be caused by CPR 117 children examined 9 positive Not caused by seizures Retinal Hemorrhages Neonates examined at 1 week
Vacuum extraction higher than C section 15% incidence Resolved usually in 1 week can take up to 6 weeks Purtscher retinopathy Ecchymosis of the chest associated with RH Terson Syndrome Vitreous hemorrhage associated with sub arachnoid hemorrhage
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