
DATE: Thursday, July 3, 1997                TAG: 9707030631

SECTION: FRONT                   PAGE: A1   EDITION: FINAL 

SERIES: OUR CHILDREN'S HEALTH 

SOURCE: BY DEBRA GORDON, STAFF WRITER 

DATELINE: NORFOLK                           LENGTH:  276 lines

DOCTORS MUST BE DETECTIVES SEEKING CLUES TO A CRIME, THEY FIRST CONSIDER WHAT THE PATIENT'S CONDITION TELLS THEM.

The toddler lay motionless on the hospital bed in the pediatric intensive care unit, wires attached to her chest, a ventilator tube taped to her mouth, her head wrapped in gauze. One eye was purple and swollen shut - the result of brain surgery to remove a huge blood clot.

The paramedics who brought her in early that morning had only been told that she'd fallen.

But the doctor knew differently.

His trained eye saw the bruises on her right and left cheek. On the tip of one ear. On her neck. The splint on her right forearm, where X-rays revealed a several-days-old fracture.

The doctor was a general pediatrician at Children's Hospital of The King's Daughters. Part of his days were spent diagnosing ear infections and strep throats.

The bulk of John M. de Triquet's time, however, was spent performing detective work of the most gruesome kind: ferreting out the physical signs of child abuse.

Two local children died in the past six weeks - one on Monday - of injuries believed to be the result of child abuse. Both came through Children's Hospital. Both were referred to de Triquet - the region's child-abuse expert.

His examinations of those children will be instrumental in any legal convictions related to their deaths.

Doctors like de Triquet have learned to understand the physiology of injuries so well that they can often tell with just a glance whether a bruise on a face came from falling down the porch steps or from a fist.

Whether a fractured arm resulted from tumbling out of a tree or from the twisting cruelty of a caregiver.

Whether a burn on a baby's feet occurred because the bath was accidentally run too hot, or because the child was held down in scalding water.

It is a grim vocation, one with no official recognition in the medical world of specialty boards and fellowships, with little funding from government or scientific foundations for research, and with limited formal training.

To be good at their jobs, these doctors need expertise not only in pediatrics, but also in forensics and forensic pathology, infectious diseases, gynecology, sociology, psychiatry, psychology, community bureaucracies and the legal system.

They must learn, as de Triquet has, to check their feelings at the door.

To be compassionate but dispassionate.

To live with the knowledge that this is a disease they can't cure, a social and cultural malignancy that just happens to have medical ramifications.

Every Monday, Wednesday and Friday, de Triquet, often with a medical resident in tow, runs his SCAN clinic: Suspected Child Abuse and Neglect.

In the outpatient clinic, he sees about 20 kids a week, most referred by the Child Abuse Center of Hampton Roads, which acts as a clearinghouse for the region's cases. Still, his waiting list is a month and a half long.

And that doesn't count the children he's called to see in the emergency room, the intensive care unit and on the medical floors.

Child abuse and neglect is one of the top 10 children's health problems in Hampton Roads, according to the Coalition for Infants and Children's Health, a grass-roots advocacy organization.

In fiscal year 1996, the latest year for which data is available from the state health department, 2,222 children in South Hampton Roads were found to have been physically or sexually abused, a 43 percent increase over the previous year. In 1995, 250 children throughout Hampton Roads were hospitalized because of intentional injuries. Nine died in South Hampton Roads.

With the additional pressures welfare reform will put on families, says Jane Stein, executive director of the child abuse center, ``we're scared to death.''

On this day, the first patient in de Triquet's clinic is a girl with glossy black hair, a shy smile and eyes decades too old for someone still in elementary school.

The computer-generated form that accompanies each child tells de Triquet why she is here: ``Medical evaluation to determine if sexual trauma occurred.''

Key to de Triquet's evaluation is establishing rapport. One of the most devastating effects of sexual abuse, he says, is the child's loss of trust. So he and third-year pediatric resident Michelle Game pull up chairs to the examining table where the child sits so they are at eye level with her.

They slowly lead her along a verbal pathway of questions, mixing the open-ended with those she can answer in one word, winding their way until they get to their destination.

``When he touched you that one time that it hurt, where did he touch you?'' de Triquet asks in his soft voice. ``You can tell Dr. D . . . it's going to let Dr. D. and Dr. Michelle know where to shine the special light to make sure you're OK, so you can help us. Where was he touching?''

But the question is too much for the little girl. She shakes her head and bites her lip.

``How about Dr. Michelle?'' he asks.

This works. She leans over and whispers into Game's ear.

Now the doctors know what to look for. They use a colposcope, a lighted instrument with magnifying lenses that allows them to peer deep into her genital area for any signs of trauma.

They look for any changes in her anatomy. For bleeding. Signs of sexual diseases. Rashes.

As they examine her, de Triquet and Game keep up a constant chattering. What does she want to be when she grows up? Who is her teacher? Does she know why frogs act like they do?

De Triquet calls it ``acoustic wallpaper,'' essential to making sure the child is relaxed enough so he can get a clear clinical picture.

This examination shows no sign of sexual trauma. And that is what he will write in his report. But, he says calmly, based on her answers to his questions, ``there's no question in my mind that this child was sexually assaulted.''

In anywhere from 15 percent to 50 percent of confirmed cases of sexual abuse, he says, there are no physical findings. It is a fact he will add to his report. But, he says, it won't make any difference in court.

After testifying in nearly 1,000 child abuse trials, he knows what will and won't fly.

``Dr. de Triquet, you didn't find anything on examination, did you?'' the lawyer will ask.

``No, but that doesn't . . .''

``But that's not what I'm asking you, Dr. de Triquet. Did you find any physical findings?''

``No, sir. But . . . ''

``Please just answer the question.''

That's why he's learned to be dispassionate. Why he teaches his residents that the diagnosis of child maltreatment is not a shot in the dark, but a careful clinical process.

``Our first priority as residents and physicians is to protect the children,'' Game says.

And sometimes, they just can't.

Pediatric neurologist Svinder Toor tells his residents he can nearly diagnose a case of shaken baby syndrome from a phone call.

Typically, he says, the story is that mom wasn't home. That the father or boyfriend was feeding the infant and the infant started crying, then stopped breathing and had a seizure.

But there's a step missing in that explanation, he says. At some point, someone shook the baby. Or threw the baby against the wall. Or slammed the baby into the floor.

Physical abuse is the leading cause of serious head injury in infants. And shaken baby syndrome is the leading cause of brain death in young children.

It shouldn't be that way, Toor says. He should be attributing brain death to the rare infectious disease like encephalitis or meningitis. Not to someone holding a child by one leg and shaking her so hard that her brain ricochets around her head, causing the blood vessels that connect it to the skull to tear.

He suspects shaken baby syndrome when he sees a child with severe brain injury and no skull fracture. Or with broken blood vessels in the eyes.

Other tipoffs are bruises on the upper arms, from gripping a child so tightly. Fractures on the back ribs, from squeezing a child while shaking her.

There is no other way those kind of fractures can occur.

And, de Triquet says, they show up on X-rays as marble-sized lumps in the middle of the rib, and their only cause is abuse.

In fact, studies show that a child could fall two or three stories and still not experience this type of injury, called a posterior fracture.

In the detective work of child abuse, X-rays are to a doctor what a fingerprint is to the police.

Not only do they show current and previous bone injuries, but they also provide a time frame for the injury.

Depending on the shade of whiteness, on the way calcium has been deposited around the fracture, doctors can date a fracture to within a day or two of its occurrence.

So if an X-ray shows that an arm was broken five to seven days ago, and the parent tries to convince de Triquet it occurred two weeks ago, he knows who is lying.

Anatomy doesn't lie.

Dr. Leah Bush is another physician often called in during the medical detective work of child abuse.

She does her work, however, after the child is dead.

The state's assistant chief medical examiner, based in Norfolk, first conducts an external exam, looking for bruises in unusual places. Toddlers typically have lots of bruises, she says. But if they've fallen, those bumps will usually be on the bony parts of their bodies: their elbows, or foreheads or chins. Bruises on the soft part of their cheeks, their upper arms or their inner thighs are signposts for abuse.

She looks for perfectly round, deep burns, the kind that are made with cigarettes, not by brushing up against a hot stove. For linear marks on the body, the kind that come from hitting a child with a cord, or a switch.

She opens their mouths and checks for bruises on their gums and lips, a sign they may have been slapped in the face.

And then she looks inside the child for the hidden signs of abuse.

If she finds a film of blood over the surface of the brain, or bleeding behind the eyes, she suspects the child was shaken or thrown. Tears in the liver, or in the blood vessels that feed the bowel, could result from punching a child in the belly.

Although her training in forensic pathology included child abuse, she said, most of what she's learned she's learned on the job.

And that's where most doctors learn about child abuse.

Four years of medical school never prepared Dr. Karen Wharton for the six cases of suspected abuse she's seen during her first two years as a resident at Children's Hospital.

It may not seem like many, but multiply her six by the other 44 residents, and the problem grows staggering.

``I don't want to be involved in any,'' she says. ``I don't want to have to see any of this.''

But it has become an important part of a pediatric resident's training, says de Triquet.

New doctors need to learn not only to be good clinicians, he says, but also to realize how often child maltreatment and neglect exist.

Wharton has learned to pick up on nonverbal clues from parents. The looking away. The emotional detachment in the face of a severely injured child. Or the opposite: an inappropriately emotional state.

She looks at the patterns of injury. Is this a child who is always falling? Who has a multitude of bruises over his body, ranging in color from the deep purple of the fresh bruise to the pale yellow of the nearly healed?

And she looks for injuries appropriate to a child's developmental stage. A 2-month-old infant, for instance, can't reach up and turn on the hot water and ``accidentally'' get burned.

The residents try, whenever possible, to focus on prevention. To be careful to say to the parent of a colicky baby, ``You need to take time for yourself. Call someone to come take the baby for a while. Take a break.''

``As a pediatrician, I think it's my responsibility to teach parents what type of punishment is appropriate,'' Wharton says. ``Putting a child in time out is. Burning a child with a cigarette is not.''

But maybe, she says, pediatricians need to do more.

``We teach (parents) what behavioral things they're going to see in their child over the coming months. Maybe we also need to teach them where the breaking point is and how to intervene before they reach for the child itself.''

After staring at the motionless toddler for several minutes, the child-abuse doctor begins his examination. He opens one eyelid to see if the pupil reacts to light.

Measures her bruises with a tape measure.

Examines her bottom, knowing that when a child is choked, as the bruises on her neck indicate, there is often sexual abuse as well.

He turns her on her side, runs his practiced hand down every one of the vertebrae that show too clearly in her thin back, feeling for lumps that might indicate fractures.

When he finishes, he gently covers her again, then goes down to radiology to view the CT scans of her head. To see for himself the large gray patches that signify dead brain tissue. Then he goes to his closet-size office, where classical music always plays, to write his report.

To dispassionately and, yes, even coldly, write the clinical facts about what he saw.

``You don't give yourself the luxury of feeling sorry for yourself, because there's always going to be another one.

``You just have to get on with the job.'' ILLUSTRATION: [Color Photos]

UNCOVERING CHILD ABUSE

BILL TIERNAN PHOTOS/The Virginian-Pilot

Third-year pediatric resident Michelle Game, right, holds the hand

of a young girl while Dr. John M. de Triquet examines her for signs

of abuse.

Dr. de Triquet shows how a baby's X-ray reveals a clue to abuse - a

broken back rib, from squeezing a child or shaking her. Abuse is the

only way, the doctor says, that such fractures can occur - even

though a caregiver will often claim that such a fracture came from a