Repair the World or Stop It From Breaking?

June 4, 2013

The three-year old boy had a low grade fever and runny nose. After reading the triage notes and peeking through the glass door, I knew he would be fine. Mom was sleeping in the corner of the room when I came in and barely awakened when I knocked on the door. Our conversation was short and to the point as I went through my routine “it’s a virus, tincture of time” talk. Leaving the room, the mom asked me for a taxi voucher. She did not want to call Freddie’s father for a ride back. With one more question, easily skipped, I learned that she and the child’s father had been fighting about their son’s cough keeping him awake. Freddie’s father had kicked them out of the house to find a doctor to “fix him or I will fix him, and you.” Turns out that Freddie and his mom were living in a house of fear and uncertainty.

When I tell someone that I work in the Emergency Department at our children’s hospital, what follows is usually something like: “That must be tough to work with all of those sick kids” or “I couldn’t do that, all of the sick babies and stuff.” The fact is, although some of the patients and families that I see do have major health issues and are seriously hurt, most have brief, acute illnesses that would resolve with a little medication or even nothing at all. Freddie will recover from this illness, but what about “that other thing”?

Here are some facts:

  1. 60% of children are exposed – either directly or indirectly – to family violence each year (Finkelhor, 2009).
  2. Stressful or traumatic childhood experiences such as abuse, neglect, witnessing domestic violence, or forms of household dysfunction are a common pathway to unhealthy behaviors, violence or revictimization, disease, disability, and premature mortality.
  3. Engaging, supportive relationships buffer children against the long-lasting impact of trauma and toxic stress.
  4. The way we speak, act, and listen in the Emergency Room setting can either provide comfort or re-traumatize a child and family.

We see kids like Freddie each day. Sometimes we can sense that something is off but are afraid to ask that next question. Oftentimes, we cannot see the problem until we ask the right questions. Emergency medical providers may not feel that learning about these issues is their role. Despite the lack of an “ongoing relationship” with our patients, the one to two hour period they spend with us is actually more time than they may have with their primary care providers. In addition, most ERs have social workers and other resources available to help handle many of the social issues that are uncovered once we start asking the right questions.

I asked Freddie’s mom if the dad had ever hit, kicked, slapped, or otherwise harmed her physically. I knew the answer, but it was an important straight question to get out on the table. She was truthful, and thankfully the answer to my next question was that the dad never hurt Freddie or his brother. She was not afraid for her life, but she wanted to improve the household environment for her kids. I gave her a resource card for domestic violence agencies in the City and thanked her for talking with me.

Over the years I have come to the realization that the result of listening and learning about these issues does not have to be an “intervention.”  We are not talking about “screening” in the classic sense, where a clear and immediate test or therapy can be implemented. What can happen when we simply “know” about the stressors and toxic events that our patients experience is that we can integrate this into the way we talk, how we make decisions about care, and consider our linkages to primary care and other resources. The first part of addressing a “chronic illness” is recognizing it. The next time you get “that feeling," see what a few straightforward, respectful questions can reveal.