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the worst case

This is the first "story" in my intermittent ongoing series on child abuse, sometimes called "child maltreatment"  or "non-accidental trauma." I have found this one very difficult to write.

I have been working on it for over two weeks, although it has been begging to be written for over two decades.

Whatever you call it, you have to come to the same conclusion: Children are sometimes harmed by the adults who are supposed to be caring for them. Whether by a parent or other relative, a family friend, a teacher, baby sitter or other older person, the point is always the same: The helpless child is at the mercy of the stronger, more powerful adult. The abuse can be physical, sexual, psychological, or a combination. It can be a one-time event, or may continue over time with repetitive events. The child might be an infant, a child, an adolescent. It is not limited to one demographic or socio-economic group. It is not just a problem in big cities, but affects children in rural areas, too. In fact, the rural areas of Southwest Virginia have a higher rate of child deaths demonstrated to be caused by abuse than any other area of the state, when looked at on a population basis.

It breaks my heart.

But then, you knew that already. The story I will tell you is not the most brutal case I have ever seen, but it is one of two that have remained with me for a very long time. It lives inside of me. I think about it always as an example of how vulnerable our children are. The story happened a LONG TIME AGO and in a different city, different state. Needless to say, I have changed names and some of the situations depicted.

Patty was nearly 2 when I first met her.

She was admitted to the pediatric intensive care unit in a coma. She was nearly brain dead, but not quite. She would never meet criteria for brain death, but she had been beaten so severely that she would never regain consciousness, never be able to eat or drink, and never be able to go home again--to anyone's home. Patty's mom was very young at the time I met her--about 16 I believe, which means she gave birth at age 14. She was well-meaning, but like so many teenage mothers, she didn't have the resources she needed to provide a loving, supportive home to the child.

There are so many children like Patty in our cities. Unplanned but loved. Unfortunately, love doesn't pay the bills.

Patty's mom was living with a man she believed she was in love with. Not Patty's father. He was apparently kind to her mom. He provided a roof over their heads, and food to eat. Unfortunately he turned out to be a "devil worshiper" and when Patty was admitted in her coma, what distinguished her from so many others in that condition I have seen over about 30 years, was the markings on her skin. Patty had a variety of markings on her skin that looked like symbols. We later learned they were symbols of witchcraft and "devil worship" and had been carved during rituals. They were permanent. The child had skin that tended to develop hypertrophied scars, called keloids that were much lighter in color than her skin. The only one I could identify was a pentagram, which had a prominent place over her left upper abdomen. But she was covered with multiple different symbols, letters, numbers. Well, only on her chest, abdomen and back, and part of her upper thighs. Invisible when she was out on the street dressed in pants and a shirt.  One of the symbols looked like it had been recently  placed, as it was a different color than the rest, and looked raw and uncomfortable. Because of how likely it was that Patty would not survive her head injury, and because of the incredible findings we had discovered the medical examiner came up to the hospital to personally examine and supervise photography of the skin markings. Every one was shocked. Even experienced nurses who had "seen it all" were sick to death at the sight of this girl.

And her mother, only a girl of 16 herself, was so frightened.

She eventually was able to tell us what had happened, and helped the police apprehend the man who had used this child in his cult for many months, and who had then beaten her severely the last time, when she objected to the process. This turned out not to be a group activity. It was solo. The man who did this to Patty was a religion of ONE. He was arrested. Patty's mom and I got to know each other pretty well over the next several months. I was the attending physician approximately every 3rd or 4th week. The child slowly recovered the ability to breathe on her own, but never was able to interact or to chew or swallow. She received a feeding tube and was transferred to a pediatric rehab hospital in the area. Although the goal was to send her home, her mother never was able to learn to care for her. She found the machines too frightening. One afternoon, I received a call that Patty was looking ill. She had a high fever and difficulty breathing. Our transport team was dispatched and brought her expertly to the ICU. Patty was suffering from pneumonia and needed assistance breathing. We were able to maintain her oxygen level in her blood adequately while we provided assistance via hand-bagging with what is known as a "bag-valve-mask" device. But whenever we stopped Patty had levels of oxygen so low they would not have been able to sustain life.

Where was Patty's mom? No one knew.

I had a nurse get her on the phone. She begged me to "save" her daughter. I asked her why she wasn't here with Patty who was so sick. She said "I can't bear to come there. It scares me too much" At that point I did something I am not proud of, and have never done before or since. I told her that I would continue to treat Patty as I was, but I would NOT put a breathing tube back into her windpipe, unless her mother was there to be with her.

If  her mom was frightened of the beeps and the blips and the machines, how frightened must Patty be, all by herself in such a foreign place?

She was not happy, but she and I knew each other quite well by then. She trusted that I would do what was necessary, but also that I was looking out for Patty's well-being. She arrived just a few minutes later. She saw her daughter, held her hand and looked me straight in the eye and asked for the breathing tube and the ventilator. I placed the breathing tube while her mother stood there crying. Once Patty was situated on the ventilator, and all the appropriate treatments for her pneumonia were underway, the two of us sat and talked. In the six months that Patty had been at the other hospital, she had made no improvements whatsoever. She did not respond to her mother's voice, or to touch or to being moved. She barely responded to pain. She did not move spontaneously. She still had to be fed through the tube. It turned out that Patty's mother did not visit her very often, while she was at the rehab hospital. She did not see what happened to her daughter on a daily basis. She just knew that she was still alive and that was what she wanted. I know I was being cruel, but I told her she HAD to stay with Patty while she was in the ICU. At least she had to stay for most of the time.

After a few days of sitting by her daughter's side, she seemed to realize that what we were doing was futile.

She also was able to tell me that one of the reasons she had not been able to "let her go" before was that the man who had used her so badly would be charged with murder once Patty died. She no longer loved him, but she feared retribution if she somehow was seen as responsible for allowing Patty to die, and allowing him to be charged with murder. Over time, while Patty was with us, with help of social workers, chaplains, and others, Patty's mother learned to let go. She understood that she was NOT acting in her daughter's best interest by insisting upon using invasive technology to keep her alive. She understood that Patty was very close to being brain dead, but did not quite fit all the required pieces of the legal definition of death. Slowly she saw that by "keeping her alive" she was enabling the medical profession to continue to abuse her. As it became increasingly clear that even after we treated the pneumonia, that Patty would not be able to breathe on her own again, her mom made the hardest decision of her life. She decided to let her go. She was ready to face the music.

Whatever that was to be.

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