Apr 24th, 2015
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A Struggle for Certainty - Protecting the VulnerableAre you sure?I ask myself.I stand there listening, watching, as the couple describe their house, its picket fences, their dog, the swing set in the backyard.Are you really sure?The question asserts itself again, in tempo with the ventilator's rhythmicwhoosh.Are we sure we're sure?Like a siren gaining volume, these piercing words distract me, threatening to derail my focus. I'm here to deliver news that won't be well received. I glance at my patient, an infant lying peacefully in his hospital crib, cherubic features obscured by the tape securing his endotracheal tube. A large subdural hemorrhage was visible on his CT scan, and the radiologist just called with more bad news: healing posterior rib fractures diagnosed on a skeletal survey. Surely there's been a mistake, I tell the radiologist, but my suggestions of overlying artifact or poorly penetrated films can't cast any uncertainty on his diagnosis. The x-rays are nearly identical to images in my textbook labeled "highly suspicious for child abuse" - bulbous bony calluses defiling the otherwise smooth contours of the ribs. Absent a reported history of trauma, my hope of deeming this constellation of clinical findings accidental is further quashed by the ophthalmologist's description: "multilayered retinal hemorrhages extending out to the periphery, too numerous to count, highly concerning for nonaccidental trauma."Focus, I tell myself, as I consider the mild-manner

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