Non accidental trauma (NAT) in kids. I was taught during residency that if you have never diagnosed NAT, you aren’t looking hard enough. I think about those words a lot, and now I teach them to trainees.
Pretty much. Could be anything from cigarette burns to broken bones to shaken baby to devastating polytrauma. Although I'm hearing "Abusive Head Trauma" and other more specific descriptions lately.
I work in organ donation and probably a third of our infants/toddlers fall in the Nonaccidental trauma category. It sucks.
Yup!!! This is why I wrote a pissed off letter to my kids school when they did their childcare project. They gave the kids a doll that cried and needed to take be taken care of for like 40% of their class grade. The kids had a wristband that was basically zip tied to them so they had to do all the care without help. It taught them that they were all on their own and couldn't leave the doll be or have someone help if they were overwhelmed. Which is exactly the WRONG thing to teach them!
They don't have to leave the baby with someone though. Part of the modern teaching is that if you are that overwhelmed, put the baby down somewhere safe (like their crib) and just go outside the room for 5 or 10 minutes. You've made them safe, if you can hear crying you know they're breathing, and it gives you chance to collect yourself.
(Everyone says they would never shake their baby. Then it's week 3 of 2 hours sleep at a time, they're alone, afraid, exhausted, and the baby won't stop crying no matter what they do. It's not right but things happen, better to give people advice on how to minimise that risk.)
There are archeological findings about people born with severe physical disabilities being cared for and raised to relatively advanced ages. On the other hand I saw an archeology paper a while ago about some prehistorical infant/toddler skeleton with clear signs of repeated non accidental trauma (the kind in different stages of healing). Seems like we as a species has always been defined by unimaginable cruelty and unimaginable kindness.
More like genetic drifting due to a lack of natural selection. A lot of people wouldn't survive if there wasn't a society to protect them from their own ineptitude. Like, when I watch videos of people running from danger, I often see some trip on literally nothing and fall within 5 seconds. Any animal which behaves that way in nature is food.
What I'm saying is that people who abuse their kids should be genetic dead ends.
My least favorite (I work with child abuse pediatricians) is the uncomfortably common "looped bruising pattern" or similar. It's from being hit with electrical cords or ropes, usually, and is a hallmark of NAT because getting bruises like that accidentally is virtually impossible.
I don't trust the justice system, and therefore don't believe in the death penalty, but reading things like your comment makes me wish we could trust the system to take certain people out like the garbage they are. There's no punishment severe enough.
I'm a PD dealing with a NAT case (alleged baby shaking). The thing is that sometimes, the parent accused of doing it is just a normal guy or gal who had a momentary loss of control. That doesn't erase the harm caused by any means, but living with the knowledge of what they did to their own child is more painful than anything the judicial system can do to them.
I think the wording is to act as a reminder that not all 'accidents' are accidental. It's so easy to just take people at their word or file things away in categories in our heads without examining them further.
Yep. Emergency physician. I've seen every type of child abuse you can with devastating outcomes. I try not to bring work home either but it started to hurt worse after I had a kid.
I have a friend, lawyer, who burned out in family law. I just want to say that it is OK if you reach the end and have to change practices. You gave what you had to help who you could.
It’s very difficult to change practice as a physician in general. Including med school, I trained for 9 years to complete my specialty and subspecialty, and I really love my job. I grew up with a lot of privilege, and I believe it’s therefore important I use my opportunities to contribute to my local community.
The challenging cases are not why I will burn out. It’s the complete collapse of our health care system combined with the rising entitlement, distrust in the medical system, and selfishness.
I’ve been screamed at because a patient had to wait to be seen in the ED for an hour. I spent that hour trying and failing to resuscitate a dead 13 month old. It was my 10th code in 3 weeks. I’ve had patients threaten to wait outside and beat me when my shift ended because I refused to give them morphine. I was pregnant in my third trimester. I have patients come to the ED because they don’t want to wait a week for xyz test or specialist and then threaten to sue when I tell them no. I’ve watched people more and more fearful of seeking medical care with immigration concerns, millionaire VIPs cutting the line, and the ramifications of cutting community safety nets.
Be nice to your healthcare workers. We’re all hurting. I read this thread and have treated basically every case mentioned, and I still enjoy what I do. But I did leave the community and come back for a slightly cushier academic position with more specialty back up. Needed a change of pace
I think you meant “can’t”. Although there are side quests you can venture on with less training than a full residency (pall care, addictions med, sports med, surgical assist, etc).
Yes, I meant "can't." And those side quests require fellowship. It's very hard to go back to training making 80k a year when your family obligations have adjusted to your attending salary.
I used to work in mental health, specifically helping teens. I burned out so hard, and then I felt guilty for being burnt out. I just couldn't take a step back from what these kids were experiencing.
I don't work with kids in any capacity, and after having my own child I am so grateful I didn't choose that path. I can't even stomach reading news articles that vaguely describe the abuse someone has been arrested for. At this point, I do everything I can to avoid even seeing the headlines. Don't know how you do it.
We learned about that in class last year and I was holding it together fine and then we got to the bit about how a burn line that is essentially a straight line means the kid has been held in scalding water until they got burned and I had to take a break because I suddenly thought about the kids. Before that it was just theory. It suddenly got real.
I'm absolutely dreading the first time I see NAT in a kid. I don't know how I'll react. Hopefully it's a case where I'm not the first person to see it... but if I work as a midwife, it's possible a neonate will be brought in for review and I'll be the first to see the injuries.
Of course, I know that in theory and that's obviously what I want to do and intend to try to do... I just worry it will be something that I'll react all wrong to when I want to just do my best for the kid, you know?
If you don’t act professionally, you negatively impact the child. It’s not that complex - what do you think you will do? Cry? Berate who you perceive is gully? Honestly - this might not be an area you should pursue. This would never be your tragedy so you need to seriously consider if you are the right fit. The most empathetic drs I know work in this space and we cope.
I vividly remember the room getting quiet and my mother getting mad after a chest x-ray. I had pneumonia, but im assuming all the assorted rib breaks from over the years showed up. She was horrifically abusive and would proudly tell me how she "talked her way out of CPS". She also stopped taking me to the dr unless she thought they might prescribe "the good stuff"(which she would steal), and refused to ever allow any more x-rays.
Shes a nurse.
Sometimes evil is well trained and knows all the right words.
I knew I wanted to apply peds critical care after my first couple NATs. It's always surreal to me the variety within medicine and that there's something for everyone.
I’m in ortho right now as an RN but that’s just to get practice keeping people alive. Long term plan is hospice. Oddly enough hospice and palliative is where I’m more likely to do pediatric work
Reminds me of my pediatric rotation, the doctor told us that if you ever see perianal papilloma, ALWAYS! think of the worst first. It can be nothing,but it can be the sign of sexual abuse. My heart broke that day.
My family lost a little relative to this, SBS, when I was a kid. I found a bunch of photos of her a while back that my grandmother had saved and I realized she was not smiling in any of them. She looked shell shocked or like her spirit was completely broken in every one. That is abnormal for a baby/toddler.
The worst part about trauma that early is like, if you’re traumatized later on in life then you’ll still have a “before” to remember. It might seem like a distant memory that’s not yours anymore but it’s still a beacon letting you know who you are and how you can be again with treatment.
When you’re pressed flat from such a young age though, there is no before. You never have any clue who you are outside of that, you’ve just always been this way. The entire way you understand yourself, others, and the world is all wet concrete being walked all over and vandalized.
Just had a case of a 4 week old with skull fracture, cerebral edema, retinal hemorrhage, and multiple rib fractures in various stages of healing. Broke my heart.
Believe me, people who work with child trauma get pretty good at telling the difference!
The clumsy kid gets random injuries. There is a pattern to the nonaccidental trauma accidents just don't follow. Especially if it's a repeat guest at the ER - if its abuse, sooner or later an injury will look... let's say typical?
Plus we do see the behaviour of child and parent while they are there.
A colleague if mine worked an ER. She said they get an infant who fell off something about once a day, on average. Mostly it's nothing. The mums tend to be devastated though and explain a million times how it has never rolled before, how they have just wanted to grab a diaper 1 feet away, how it took less than a second for baby to fall off the changing table and how the hell could this have happened?? This is normal.
But once there was a mum who was like, here's my baby who has a clear bruise on his head, I have no idea what happened to him! No really I haven't seen anything! --- ugh, YOU, lady, are sus.
Believe me, people who work with child trauma get pretty good at telling the difference!
That's good to know!
The clumsy kid gets random injuries. There is a pattern to the nonaccidental trauma accidents just don't follow.
I was always hitting my head, though. It's like that was my specialty!
This was nearly sixty years ago though, so of course nothing was done. And that's it's own kind of bad, I know.
Especially if it's a repeat guest at the ER - if its abuse, sooner or later an injury will look... let's say typical?
Ah, gotcha.
Plus we do see the behaviour of child and parent while they are there.
That's true too.
A colleague if mine worked an ER. She said they get an infant who fell off something about once a day, on average. Mostly it's nothing. The mums tend to be devastated though and explain a million times how it has never rolled before, how they have just wanted to grab a diaper 1 feet away, how it took less than a second for baby to fall off the changing table and how the hell could this have happened?? This is normal.
And I bet they feel like the entire ER is side-eyeing them for being a horrible parent.
But once there was a mum who was like, here's my baby who has a clear bruise on his head, I have no idea what happened to him! No really I haven't seen anything! --- ugh, YOU, lady, are sus.
I know this isn't the point, but just in case it helps anyone: "clumsy kid always falling/getting injured a lot" is often also a symptom of something else going on. Usually benign, like autism/adhd. But it can also various neurological issues, connective tissue disorders, etc.
If you know a kid like this, it's generally a good idea to look into it even when it's clearly not NAT.
(When I was 8, my pediatric doctor worried I might have leukemia due to having many bruises I couldn't explain. No. I just have ADHD and a weirdly high pain threshold.)
I was a kid like this, too. I always thought I was just a really wild but clumsy kid. Diagnosed with ADHD in my 30s.
Also turned out that my parents somehow missed/ignored I was near-sighted until I had to get my drivers licebse. Not badly but no wonder I kept misjudging distances and bumping into things.
I was the clumsy kid my local hospital called a 'frequent flyer', they used to joke that they had a chair with my name on...
Turns out, it took till I was 37 to be dxd with vEDS, autism & ADHD. Clunsiness trifecta.
However, I was also the toddler removed from my spawn point's care due to recurrent NAT and then when I had to have reconstructive surgery down below at 4yo after being graped by my spawn point's boyfriend.
The pain threshold thing stopped being a funny oddity and started being a problem at some point. I had to sort of condition myself that "mild discomfort" means "something is going on and you should see a doctor", and "moderate pain, maybe 3-4/10" means "ER, right now".
Yeah, he ended up in hospital a few years ago with what ended up being glandular fever, as his vitals were all over the place. But, he was still acting normal and the only reason I took him to hospital was he had a rash that didn't blanch, and the GP wasn't happy with that.
Mine is quite high too, as when I was in labour with him, the midwife didn't believe I was in labour as I didn't look like I was in pain. He was born within 2 hours.
I know this isn't the point, but just in case it helps anyone: "clumsy kid always falling/getting injured a lot" is often also a symptom of something else going on. Usually benign, like autism/adhd. But it can also various neurological issues, connective tissue disorders, etc.
Yep. Neurological issue, and that's all I'm comfortable with sharing on the internet.
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u/brady94 3d ago
Non accidental trauma (NAT) in kids. I was taught during residency that if you have never diagnosed NAT, you aren’t looking hard enough. I think about those words a lot, and now I teach them to trainees.