The loss of a child has a devastating effect on a family, particularly when it is unexpected or without any readily identifiable cause. These families do not have the opportunity for “preparatory grief.” Proper ED management is critical to the family’s long-term adjustment.
Clinical Presentation and Diagnosis
When the ED is notified of the transport of a child in extremis, assign a resuscitation team member to work with the parents. Take the parents to a quiet area not far from the resuscitation scene, and have that team member act as a liaison to keep the family informed. In some centers, parents will be present in the resuscitation room, but a staff member who can interpret the events must accompany them.
At the time of the child’s death, notify the parents privately, clearly, and directly. Specify the word “dead” to avoid any confusion. Avoid using euphemisms like “He has passed.” Once the death has been communicated, the management phase begins.
Family members may display many emotional reactions, from hysterical screaming, to anger, to silence. All responses are normal. Once the immediate reaction has had time to occur, be available to answer any questions. There is no need for excuses, although parents may appreciate expressions of personal emotion and concern. Respond to parental expressions of guilt with a realistic appraisal of the circumstances. Also try to obtain additional history that may be helpful in establishing a diagnosis. If abuse (pp. 604–608) is suspected, it will be confirmed at autopsy, so there is no need to confront the grieving family.
Provide the family with assistance: phone, water, tissues. Do not assume that they want a particular relative or clergyman unless they so request.
Encourage parents to see the child’s body once it has been prepared for their viewing (removal of medical equipment, soiled linen, etc.). Allow parents to hold the child’s body and say their farewells. A prayer or closing ritual said over the body is a good way to bring closure after a brief period of contact with the child.
Inform the family of any requirements concerning an autopsy. In most states an autopsy is not mandated if the child had a chronic condition in which death was expected. If there are no requirements, encourage an autopsy in order to answer any questions pertaining to the cause of death. Also discuss the possibility of organ/tissue donation with the family. Instruct a trusted family member or friend about hospital policy on claiming the body and other necessary arrangements.
Give the parents your contact information in written form for follow-up questions and concerns, and document the chart and death certificate appropriately. Contact the child’s primary care provider, along with any relevant subspecialists, to notify them of the child’s death. Afterward, a brief staff meeting may pull staff members together and allow them to express their feelings.
Interpersonal violence is an altercation between two or more non-caretaker individuals in which at least one of the participants intended to harm the other. These altercations frequently occur in the school, schoolyard, or street. In general, it is not useful to apply the terms “victim” and “perpetrator,” as the “victim” that presents to the ED may have instigated the fight that he or she subsequently “lost.” It has recently been reported that as many as 25% of all adolescents seen in a pediatric ED were treated for injuries resulting from interpersonal violence.
In contrast, family violence, such as child abuse and domestic violence, is characterized by one individual having significant power over another within the relationship. While most healthcare systems have protocols for the management of family violence, there is no mandated reporting system for interpersonal violence.
Clinical Presentation and Diagnosis
Violently injured patients present with a wide range of injuries and injury severity. Prior to the interview, assure the patient that all responses are confidential, with the exceptions of suicidal or homicidal statements and the disclosure of child abuse. Let the patient tell the story in his or her own words, in private, and listen non-judgmentally. After the interview, ask the youth’s permission to involve the family in the discussion. Enlisting the help of the family can often facilitate follow-up and ongoing support for the patient.
The responses to a few suitable questions can determine the need for immediate referral to social work, mental health, or law enforcement (Table 19.1). Clearly document these responses in the medical record. The legality of access to the medical record by law enforcement agencies varies among communities, so contact the hospital’s legal counsel regarding local statutes and recommendations pertaining to documentation.
|Relationship to the other participants|
|Use or appearance of weapons at the scene|
|What caused the event|
|Access to weapons|
|Depression: long-term plans, presence of family and close friends|
|Retaliation plans by patient, family, or frienda|
a Requires immediate referral to police.
b Requires immediate referral to psychiatry and social work.
A thorough evaluation of the violently injured patient includes an understanding of what caused the event, the location and time of the episode, the relationship of the patient to others involved in the incident, and the use or appearance of weapons at the scene. Explore issues related to the patient’s safety. Ask specific questions regarding any intention to hurt themselves or others. Also inquire if a family member or friend plans to retaliate. Although open-ended questions such as “Once you leave here, what are you going to do?” can clue a physician into potentially dangerous plans, ask directly about retaliation and suicidal thoughts. Similarly, ask the patient about drug selling, access to weapons, and possible gang affiliation. When present, these risk factors may predict the lethality of future actions. When asking about substance use and abuse, also inquire about the patient’s friends and acquaintances, to determine potential exposure to that lifestyle. If the patient admits to using marijuana or other drugs, ask “why.” The responses to these questions may help confirm that the adolescent is self-medicating.
Assess the patient’s present emotional state and reaction to the trauma. Since there is a strong correlation between depression and the risk of violent injury, ask about the patient’s long-term plans for the future and the presence or absence of close friends or family members as confidants and allies.
The primary psychological goals of ED care of a violently injured youth are to stabilize the patient, ensure the immediate safety of the patient and other participants, and to assess the patient’s risk for further injury. If the patient reveals suicidal or homicidal intent, contact a psychiatrist immediately. Also, the medical staff is obligated to contact the police if there are legitimate concerns about retaliation.
It is also important to assess and address the psychosocial comorbidities, including depression, substance abuse, school failure, and family violence. Refer a depressed or hopeless patient to a psychiatrist urgently. Provide psychosocial support to all violently injured patients, regardless of the situation that caused the injury. Consult a social worker, who can help provide access to available community resources. Give contact information for appropriate crisis hotlines, community support groups, and available local shelters. Information about these resources is often also available from municipal social service agencies.
If the patient is being admitted, communicate any safety concerns to the inpatient medical and nursing staff, security officers, and social workers. One-to-one observation is necessary for suicidal or homicidal patients. If there is any concern for gang retaliation, it may be necessary to admit the patient under an alias to ensure his or her safety.
Indication for Admission
Active suicidal or homicidal ideation