I was pulling another 10-hour shift during my pediatric residency at a children's hospital in North Philadelphia when the ED glass doors slid open and a police officer carried in a bruised and bloody 4-year-old wrapped in a blanket. The two looked like the characters in the old Boys Town Christmas seal: "He ain't heavy, he's my brother." The boy was rigid and silent, and his dark eyes turned to me in dazed apprehension. In some places his straight, black hair stood up, and in others it was matted with blood. The officer explained that he and his partner had found the naked boy wandering under a railroad trestle behind an abandoned factory. The officers had made a quick search for the boy's clothes, but not finding any they packed him into their patrol car and brought him in. As the officer carried the child to the gurney, he explained that he had raided our linen closet so he wouldn't have to carry the naked boy into the air-conditioned examining room. Where were this kid's parents? I wondered. The officer, as if reading my mind, said, "We haven't had any kids reported missing, but we'll call if and when we do." I thanked him and turned my attention to the boy. "Hi," I said, hunkering down to his eye level. "What's your name?" "Mikey," he replied, looking down. "Do you have another name, Mikey?" I asked. "No. Just Mikey." "Do you know what your mommy's name is?" I asked. "Mommy," he said. His eyes quickly filled with tears. "It's okay, Mikey," I said, patting his back gently. "It's okay. We're going to find your mommy and get you cleaned up. What happened to you, Mikey?" He was silent, so I moved closer and asked my question again, almost in a whisper. "Some boys threw rocks at me," he finally replied, looking down again. "But what happened to your clothes?" I asked. "I don't know." And I believed him. There would be more time to figure out how he got hurt after we figured out how hurt he was. I immobilized his neck in a cervical collar, and then I pulled back the blanket of comfort and security and started my examination. His heart and lungs were fine, and there was no sign of blood behind his eardrums. I had to spend a little extra time examining his eyes. They were so dark it was difficult to tell where brown iris ended and black pupil began. Mikey had bruises all over his back, arms, and calves. On the back of his head were two fat goose-egg lumps. It appeared he had lain on the ground and tried to cover his head with his hands. As far as I could tell, there were no broken bones. There was, however, a two-inch gash that started in his scalp and ran down onto his forehead. It had bled for a long time, the way scalp wounds usually do, and Mikey's hair was slicked down his forehead with the sticky tar of congealed blood that gave off that familiar metallic scent. Because Mikey couldn't tell me what had happened and there seemed to be no witnesses, he needed a full trauma evaluation with all the blood work and x-rays that came with it. The unit clerk opened a trauma kit that held prestamped paperwork and lab slips with an assigned number in place of the patient's name. For the moment I took comfort that I at least knew his first name. It was a place to start. And I found myself starting over, as I do every time I take care of a child whose injuries are entirely preventable. I'd never seen a case of polio, measles, or diphtheria, but I had seen children shot, drowned, shaken, and hit by cars. My patients mirrored the national trend: more had died of injuries, neglect, and abuse than from all the birth defects, cancer, heart disease, and HIV infection combined. The nurses eased Mikey through a blood draw that would evaluate how much blood he had lost and whether his liver had been damaged. Mikey dutifully urinated into a cup so we could check for blood. I taped gauze over the gash on his head, and the nurses cleaned off some of the dried blood with peroxide and put him in a clean gown before wheeling him off to radiology. I called admissions to get Mikey a room for overnight observation and wondered how he was going to do when I stitched his head. It always helped when a parent or friend was there to hold the child's hand or to talk or sing. But it had been almost an hour since the police had dropped him off, and there was still no sign of his mother. Where could she be? Most parents would have missed a 4-year-old by now. The fatherly officer was long gone, and the sex-crimes detective was on the way. When Mikey returned I was going to have to swab his throat, penis, and rectum to culture for gonorrhea and chlamydia because it was my job to determine just how cruel these boys (if Mikey was right) had been. I reviewed Mikey's films with the radiologist. The black-and-white slices of Mikey's brain looked normal. There was no skull fracture lurking under the hematomas, and his abdomen and spine had likewise escaped serious injury. When Mikey and I got back to the ED, the unit clerk pointed us out to the sex-crimes detective. The detective reported that Mikey's mother had finally called the police and would be here soon. I reported what I knew so far: no fractures, no internal injuries, multiple bruises and abrasions, and one good-sized laceration. The detective asked if there was evidence of sexual abuse. I said that I was just getting to that part. Mikey climbed back on the gurney, and I explained to him that we were going to look at his private parts. He rolled over on his belly and then onto his back. The nurse and I kept up our patter of small talk and distraction as I took samples. This examination, I knew, was as violating as anything Mikey might already have suffered that long, long night. It was another half hour before his mother arrived, jumped on the gurney, and hugged Mikey to her chest. He hid a wince—from pain or fear or maybe both. She had last seen him playing in the backyard at 3 o'clock, she said; when she checked later, he was gone. She assumed he'd gone next door to the neighbor's house. When he didn't come home for dinner she called the neighbor. It was another two hours before she called the police. I asked Mikey's mother for the information I needed for my report to the child protective services, and I explained that he needed stitches. When she told me she couldn't bear to watch, I asked her to go out and register Mikey in admissions for his overnight stay. His cut was still oozing; the nurse and I teamed up again as I anesthetized the area and cleaned it. Mikey never moved as I described the children's playroom upstairs and put in 12 stitches. I wrapped gauze around his head and waved good-bye as the nurse wheeled him away. I never saw those serious dark eyes again. His mother came back through the ED and was surprised to find that Mikey wasn't where she had just left him. I explained that he had already gone up to his room. The sex-crimes detective checked in with me twice that week. The first time he asked if any of the cultures had come back positive for sexually transmitted diseases. They hadn't. The second time he stopped by because he was in the neighborhood. He didn't have any suspects in Mikey's case. Child protective services had sent Mikey to live with his grandmother. Mikey, we agreed, knows what happened. Behind Mikey's dark eyes the secret stays, and part of the secret is that a child barely old enough to tie his shoes can be found bruised and battered miles from his home and no one knows why. Not his mother, not the neighbors, not the police, not the doctor. Mikey's trauma is beyond the resolution of our CT scanner. My image is of him whimpering in his sleep while his grandmother rubs his back and soothes him, saying all the while, "You're safe now, everything's all right." Like other abused children I've known, Mikey may start wetting the bed; he may scream if he's left alone. Someday I imagine Mikey studying the scar that winds its way into his hairline and thinking of his time in the emergency department and how it changed his life. Mikey and I will haunt each other's lives: neither will be able to put that night to rest. Between Mikey and me, the full story remains unwritten, and the fragments humble our belief in parenting, protecting, and healing.
JAMA – American Medical Association
Published: Sep 15, 1999