Approach to Vulnerable Populations

Abstract

Trauma informed care, tonic immobility, fight, flight, freeze, labor trafficking, human trafficking, reporting hotline, bruises, bites, irritability, mandated reporter, suspicious fracture.

A Word on Vulnerable Populations

Trauma Informed Care

We should all be aware of the Neurobiology of Trauma.

• High stress and fear impair our prefrontal cortex so one “cannot think straight.”

• We cannot focus our attention, draw on reason or past experience, cannot think it through or inhibit our impulses.

  Results in a FIGHT FLIIGHT FREEZE state

  • Self-protection habits kick in

    • being polite to dominant/aggressive people

  • Disassociation is common

    • blanked out/spaced out/fog/dream

  • Tonic immobility

    • frozen state—cannot move or speak can last seconds to hours

  • As a result of the cascade of hormonal and chemical changes from trauma patients do not lay down memory in a sequential pattern.

    • Comes across in “Bits and pieces” of memory

Human Trafficking/Labor Trafficking

• What is Human Trafficking? The act of coercion, fraud, or forcing a person into leaving their home to work for little or no payment.

• What is Labor Trafficking? The recruitment, harboring, transportation, provision, or obtaining of a person for labor or services through force, coercion, or fraud.

  • Child victims often present with complaints related to their experience trafficking

  • These include:

    • work-related injuries

    • exposure to toxins

    • bruises and scars

    • exhaustion

    • malnutrition (See Fig. 25.1 )

Fig. 25.1

Child labour

To harbor safe interactions one needs to remember to:

• Keep the survivor on the forefront of our interactions—Victim Centered

• Safe space

• Traumas create triggers (sights, sounds, emotions)

• Send an authentic message

• Realizes the widespread impact of trauma

• Responds by integrations of knowledge

• Seeks to resist re-traumatization

Red Flags to Identify Human Trafficking victims:

Physical Exam

• General Appearance: Appears malnourished, limping /pain

• Skin: Trauma, scars, rashes, sunburn, track marks, branding

• Gyn/GU: STI, trauma, foreign bodies, unknown pregnancy

Other Signs

• Lack of control

• Minor not in school

• Does not speak English

• Alcohol/drugs

• Trauma

• Unfamiliar with surroundings

68% of Human Trafficking Victims access Healthcare While Being Trafficked!

Every hospital or institution should have a protocol to report suspected victims

National Reporting hotline: 1-888-373-7888

Child Abuse:

Means:

• 1. Intentional infliction of physical or mental injury upon a child

• 2. An intentional act that could reasonably be expected to result in physical or mental injury to a child.

• 3. Active encouragement of any person to commit an act that results or could reasonably be expected to result in physical or mental injury to a child.

Recognizing Child Abuse

Pay Attention to the Following

History

Physical Examination

Lab Studies

• The history does not explain the injury found.

• Multiple injuries of various types or ages

• Delay in seeing medical attention for an injury which is obviously serious.

• No history offered to explain an injury which is serious or typical of abuse.

Types of Discrepancies Between History and Injury

• History changes over time or different caretakers give different stories.

• Child is developmentally incapable of having acted as described.

• Child would not reasonably be expected to have acted as described.

• Serious injury blamed on another child.

Rules to Follow

• 1. Those that do not Cruise Rarely Bruise!

• 2. Follow the following TEN-4-FACES bruising rule

  TEN 4-FACES Bruising Rule

  Any bruise found in any of the following locations should trigger the possibility of pediatric physical abuse.

  Torso

  Ears

  Neck

  Any bruise in a child younger than 4 months old

  FACES

  Frenulum

  Angle of the Jaw

  Cheek

  Eyelid

  Subconjunctival Hemorrhage

• 3. Be AWARE of patterned bruises

  • (a) Linear bruises to buttocks

  • (b) Linear bruising to the pinna

  • (c) Retinal bleeding

  • (d) Handprints or oval marks

  • (e) Belt marks

  • (f) Loop Marks

  • (g) Ligature marks, circumferential rope burns to the neck, wrists, ankles, or gag marks at the corners of the mouth

• 4. Too many bruises

• 5. Any fracture in a non-ambulatory child

• 6. Bonks (see Fig 25.2)

• 7 . Bites—any human bites

• 8. Baby blues (irritability) (Fig. 25.3)

Fig. 25.2

Pittsburgh infant brain injury score for abusive head trauma

Fig. 25.3

Child presenting with injury

Question if Accidental

• How foreseeable and preventable was the accident?

• How do the caretaker’s actions compare to the standard in the community?

• What is the overall level of concern about the child’s welfare?

• What is the potential for the child to be injured again?

Fractures Highly Specific for Abuse

• Metaphyseal lesions

• Posterior rib fractures

• Scapular fractures

• Spinous process fractures

• Sternal fractures

Final Points

• We are advocates for children!

• Pay attention to clinical clues in history and the physical exam findings.

• Call for resources for families in need.

• We are mandated reporters.

Do the right thing for the child, and help to prevent the future catastrophe!