When a Medical Specialty Is Not A Specialty At All

When my twin sons were five, my husband built a treehouse in our backyard complete with a trapdoor, porch, climbing wall, rope ladder, and zip line that sent the kids from the tree house porch across the yard to another tree. It was just as fun as it sounds. Not content to use the zip line as it was intended, one of my twins decided to go at it backwards. After a running start on the ground, he planned to swing on the zip line, bounce off the handle of the shovel he had staked in the ground at the midway point, and catapult himself onto the treehouse porch. It was a bold and imaginative strategy. He never made it past the shovel.

I was running an errand, but my husband was in the backyard when my son fell off the zip line from a height of four or five feet and landed on his right side. I returned in time to see him sitting under a tree holding his right arm and crying that it was broken. His arm didn’t seem to be injured — it wasn’t swollen and he had full range of motion — so we carried on with our evening.

For close to two weeks, my son would occasionally say that his arm hurt, but we dismissed it because he fully engaged in all his regular activities with no problems. His arm also looked completely normal: no bruising, no swelling. He played in a soccer game the day after he fell. He played in three T-ball games over the next two weeks — one of which was five days after he fell — and in two of those games he played pitcher, repeatedly fielding the ball and throwing it to first base with his right arm. He also batted using both arms in all three games.

Almost every morning for those two weeks, my son dribbled a basketball with his right hand. He climbed up the rock formations at an arboretum using both hands to balance his weight. We have a video of him swinging across the monkey bars using both arms. He used his right hand to practice writing every morning during the week without complaint.

He went to preschool five times within those two weeks, and his teachers noted nothing concerning except that he once whined after falling off a beanbag. His teacher mentioned that it was odd that he said anything about it because he normally didn’t complain about falling. Right after I picked him up that day, he took off his ice pack and climbed a tree outside the school.

Ten days after the fall, my son fell down in his room and then ran crying into the kitchen. He said, “My arm is broken! Take me to the doctor so she can fix it!”

Testing him, I asked, “When did your arm start hurting?”

“When I fell off the zip line.” Soon thereafter, I observed him using his left hand to eat his lunch when he didn’t know I was watching.

Starting to be concerned, I texted my husband, I think there might actually be something wrong with his arm. He just fell and now he’s eating with his left hand. Do you think it could be broken?

My husband texted back, How could it possibly be broken? He’s been walking around like that for close to two weeks.

Could it just be bruised? I wasn’t worried before but now I am a little.

Make an appointment with the doctor. I’m sure he’s fine, but an appointment will make you feel better.

About two hours before the doctor’s appointment, I shot a video of my son dribbling a basketball with his right hand. He exhibited full range of motion during the doctor’s exam. He had no reaction when she touched his arm except to acknowledge that it was painful when she touched the sore spot. The doctor said she thought it was likely just bruised but, to be sure, she sent him down the hall for x-rays.

To my great surprise, the initial x-ray showed a fracture. It looked like a small break on the edge of his radius, so I thought perhaps it wasn’t a very significant break. While I waited for follow up instructions to see an orthopedic doctor, both twins took turns throwing themselves against the wall in the hallway for fun.

Soon after the initial appointment, my son had another x-ray at an orthopedic office that showed he had broken his radius straight through. It wasn’t a small little crack on the edge of the bone like I initially thought. This was a complete break. By this time, it had been broken for so long they didn’t even bother putting a cast on it.

I was dumbfounded to learn that his arm was broken. I asked the orthopedist, “How could he have managed to do all of these things with a broken arm? His older brother pulled him into the air by his hands playing a game, and he was laughing. Why wouldn’t that have been painful? Why didn’t he cry?”

The orthopedist immediately responded with a super-technical description of how different positions put different amounts of stress on different parts of the arm. As he explained this, a wave of understanding washed over me: if this man had been the doctor assigned to the child abuse investigation against me three years prior instead of a child abuse doctor, I wouldn’t have been blamed for that child’s broken arm.

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I worked as a Child Protective Services social worker for ten years prior to being investigated for the broken arm of a child I babysat in my home. As a CPS worker, I was aware of how critical medical opinions are in investigations. Armed with a doctor’s statement of how an injury occurred, you can travel down the road to a criminal conviction or confirmation of abuse. Without a doctor on record, you’re stuck.

Blame for the one-year-old’s spiral fracture fell on my shoulders for a variety of reasons — exceedingly poor interview skills, outrageous confirmation bias, an almost complete lack of critical thinking skills, misrepresented statement in police reports — but one of the biggest reasons was the professional reaction to a little girl playing a set of bongo drums.

I liked to send the child’s mother pictures and videos throughout the day so she knew what we were up to. Around 10:30am on the day in question, I sent her a video of her daughter cheerfully hitting a set of bongo drugs with both hands. In the video, the child looks completely unbothered and rather pleased with herself. I didn’t know when I hit send that the short clip would be a central component of my undoing.

When trying to determine when a preverbal child is injured, you have only their behavior to reference. When was she cranky, and when was she not cranky? When did she favor her arm and when did she not favor it? When did her behavior change, and what activity was she engaged in right before the behavior changed?

In her report, the child abuse pediatrician wrote, “At 10:32 a.m., Verbanic sent a video to the child’s mother of the child playing the bongos using both arms. She had no sign of pain or discomfort at this time.”

In a log note detailing her conversation with the doctor, a CPS supervisor quoted the doctor as saying “there were no signs of injury” when the child played the bongo drums. The doctor added, “With the injury/broken arm the child would not have been able to use that arm as depicted in the video.”

I was the only suspect despite obvious clues like the child’s mother suggesting five times to the police that the injury could have occurred at her residence before the child was dropped off at my house. Since investigators and the doctor decided she wasn’t injured while playing the bongo drums at 10:30am but was cranky at home that night, they believed I had to have broken her arm sometime after 10:30am but before she was picked up by her mother at 4:30pm.

I lived the day in question, and so I knew that she was out of sorts right when she entered my house with her father and continued to be mildly grumpy throughout the day. Both before and after the bongo drums, she whined more than usual when I touched her but was otherwise fine. I thought she was teething because her father didn’t give any information at the drop-off to suggest otherwise. Her mother confirmed that she behaved similarly in the evening at their house: she was whinier than usual but only cried when someone touched her arm. Just like my son, sometimes she cried about her arm and sometimes she didn’t. Her mother didn’t take her to the emergency room until around 8pm — over three hours after she was picked up — which indicates that even her mother didn’t immediately notice anything wrong with her arm.

The bongo drums video was a snapshot in time. I didn’t take videos every time she whined when I touched her arm before or after the bongo drums because I didn’t know I would need them for context in a child abuse investigation.

The child wasn’t verbal because she was one year old. My son was five when he broke his arm and was able to clearly tell everybody how it happened. If he had been nonverbal and couldn’t tell you when he broke his arm, you would never, ever, ever look at the videos of his behavior for the two weeks after his fall and think that his arm was broken. In fact, you would look at them and think it couldn’t have been broken, which is why we didn’t take him to the doctor for almost two weeks.

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“The child would not have been able to use that arm as depicted in the video.” There is no hedging in this statement made by the doctor to CPS. She is stating clearly and unequivocally that the child would not be able to hit a set of bongo drums with her hand while her arm was broken. I know because of my lived experience — both with the child on that day and with my son a few years later — that what the doctor intended as a definitive statement was actually just a really bad guess.

I have no medical training, but I know that a child can hit a set of bongo drums with a broken arm just like I know that a child can swing on monkey bars, throw a baseball, dribble a basketball, and be picked up by his hands with a broken arm. I know because I watched it happen in real time. Twice.

Judging what an individual can or cannot do with a broken arm based on their demeanor or what the injury looks like in a video is not science — it’s an assumption likely resulting from personal bias. I know adults who have gone about their regular business for days with an undiagnosed fracture, and I also know adults who are incapacitated by a minor head cold. Kids aren’t any different. How someone responds to an injury does not always depend on the injury itself, and so we can’t say what is possible based on how something looks or how we assume someone would feel.

When I asked how he could have been picked up by his hands without crying, my son’s orthopedist didn’t say anything about his response to the pain. He talked about the mechanics of the movement.

I don’t fault the child abuse pediatrician for not knowing as much as an orthopedist about what children can and cannot do with a broken arm, just like I wouldn’t fault my primary care physician for not knowing how to treat cancer. Instead, I fault the child welfare system for setting it up so that non-specialists are giving opinions on injuries that can potentially send parents to prison. Child abuse takes many forms — sexual abuse, bone injuries, brain injuries — and we can’t expect specialist-level knowledge in each of these areas from what is essentially a general practitioner. Child abuse pediatricians have to be a jack of all trades, but we label them as experts.

My primary care physician (PCP) referred my son to a specialist after the initial x-ray because we know that an orthopedist knows more than a PCP about bones. We do the reverse in child abuse cases: instead of referring to someone who is the most specialized in the injury in question, we refer to someone who is not specialized at all but instead works in the incredibly broad field of child abuse.

If the argument is that the child abuse pediatrician can get a second opinion on the injury, I question the rules and regulations for doing so. Do we even have rules and regulations for this? Is a second opinion mandated, or just a suggestion? Does a second opinion occur in every case, or is it up to the child abuse pediatrician’s discretion? If there is disagreement, who gets the final say — the specialist or the child abuse pediatrician?

The doctor on my case got a second opinion from a co-worker in her office. This is not a second opinion. It’s an echo chamber.

It has been suggested to me that specialists (orthopedists, gynecologists, etc.) are not trained in the ins-and-outs of child abuse, and this is what makes a child abuse pediatrician a necessity. I disagree. Instead of creating an entirely new field, why not just train the specialists in child abuse? As someone who investigated child abuse for the state, I can testify that we want to arm our social workers and police officers with the correct medical information so that they do not conduct their entire investigation based on a flawed opinion. And as someone who has been investigated for child abuse, I don’t want my life or the wellbeing of the child I babysat for to be in the hands of someone who guessed wrong. Who can argue against this?

I know from work experience that child abuse cases can become a convoluted mess of fear and ambiguity. The high emotions we feel when children are hurt adds to the pressure to get it right, and this can lead to emotional reasoning and hyper-reactivity. We need experts who can help light a clear path with specialized knowledge of the injuries in question.

When I have described my son’s injury to friends or acquaintances, I’ve never had anyone disbelieve it. More often than not, they respond to my story with their own tale of a child going days with an undiagnosed fracture or other injury. The orthopedist who treated my son did not flinch when I described the things he did with a broken arm. Neither did the primary care doctor who treated him initially.

In contrast, the child abuse pediatrician who handled the case against me believed — erroneously — that children cannot perform activities with a broken arm. I narrowly avoided going to jail for something I didn’t do, and her faulty opinion was a major factor in that.

Most people who experience the child welfare system are disadvantaged and cannot defend themselves against professionals who hold the power. Children and families served by the system deserve the best we have to offer. Let’s make sure we give it to them.