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Hi there!

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Real quick before we start the podcast, I want to recognize today is October 4, 2023,

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as in 10/4.

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10/4 is the acronym for concerning injuries that MCP, Mary Clyde Pierce, and her team

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created.

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So, on October 4, many states used this as a moment to spread the "10/4" message,

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and we at EM Pulse agree.

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We want to share a special resource that you can use in your practice to identify skin

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injuries in kids that may point to abuse.

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Also, the EIIC, or Emergency Medical Services for Children Innovation and Improvement Center,

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has created another wonderful PEAK.

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A PEAK is a pediatric education and advocacy kit, and this one is focused on child abuse

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for emergency departments.

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The goal of these peaks is to help clinicians identify and care for abused children in emergency

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departments.

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And this podcast is a part of that toolkit.

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So, check it out at emscimprovement.center or check out the link with inside of our notes.

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All right, now let's get started with our podcast.

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This is EM Pulse with your hosts, Sarah Medeiros and Julia Magaña.

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Welcome back to EM Pulse.

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On March 17, 2023, we replayed or repeated the powerful podcast, "It Could Have Been Different".

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That podcast reviewed the work of Dr. Mary Clyde Pierce, my friend and mentor.

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We heard the story of a nurse whose child was abused and the opportunities the medical

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community had to prevent the severe abuse the child endured.

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We also heard from Dr. Pierce about the simple tool 10-4 FACESp that we can use in the emergency

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department setting to screen for concerning injuries in children less than four years

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of age.

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Now, we are back with MCP again with an update on 10-4 FACESp.

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Now remember, Dr. Mary Clyde Pierce is a pediatric emergency medicine physician, child abuse

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injury researcher, and professor of pediatric emergency medicine and preventive medicine

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at Northwestern University Feinberg School of Medicine.

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Welcome back, MCP!

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Woo hoo!

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I am excited to talk about this again because there are some really important updates to

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this body of work.

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So let's get into this.

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So let's walk through the acronym for 10-4 FACESp.

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What does that stand for?

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Yeah, okay.

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So let's do the regions first and then we'll do what the number in the P stands for.

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So the regions are 10 and faces stands for regions on the body that were predictive of

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abuse versus an accidental injury.

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So T stands for torso, which is really basically your chest, abdomen, back and buttocks.

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So you should trunk.

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So T stands for torso, E stands for ear, either of them or both.

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N stands for neck.

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F stands for the frenulum and you have three of them in your mouth, the upper gum, the

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lower gum and then under your tongue.

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A stands for angle of jaw.

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That was a very interesting finding.

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So A stands for angle of jaw.

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C stands for cheek, but the fleshy part,

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you know, the part that's that little cute part

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that's right by your mouth and not the hard part

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that's up below your eye.

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So the fleshy part of your cheek.

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E stands for eyelids.

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And then S stands for subconjectiva.

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So when your subconjectiva have a hemorrhage,

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it's a very red appearance.

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And then P stands for pattern.

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So any kind of pattern like a loop mark or linear marks.

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And then the four actually has kind of a double meeting.

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First off, the rule only applies to children

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that are under four years of age.

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But importantly, our studies show that any bruising anywhere

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on infants that are four months of age and younger.

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So if you're four and a half months age,

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any bruise anywhere, it was actually predictive of abuse.

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So any bruise anywhere for infants that are four months,

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4.99 months literally, and younger, predicted abuse.

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I love the simplicity of this.

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And we were just talking before the podcast started

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that I was using this rule earlier today on a consult

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that I was doing in the emergency department.

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But MCP remind us,

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what is the significance of injuries in these areas?

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What does this mean?

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Why is this important?

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- The whole passion began by trying to figure out

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and identify abuse very early on.

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And what we see over and over again,

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that, you know, like we said in our previous podcast,

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bruises are often dismissed as unimportant injuries and medically they may not typically

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are usually, they're not really that important, but when they tell you a story, the bruises

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actually tell you a story.

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And in fact, the research we've been doing recently with fractures that you're helping

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us with and also our bruising research and our head injury research, what's interesting

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is that bruises seem to be a hallmark of a more violent form of abuse.

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So when you see bruises, you actually need to get extra concern, which is really interesting.

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We had more fatalities in our bruising study than other studies.

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So it's a marker of possibly even a more dangerous or severe environment.

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But of course bruises occur from both accidental and abusive trauma.

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So it's really based on the principle that when somebody physically attacks a child,

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they go for very specific regions.

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There's some kind of like primal thing inside humans where they attack them around the neck

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or around the mouth or around the abdomen.

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And those areas are hit them on the side of the head.

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So those areas over and over again kept predicting abuse.

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And so that's why we wanted to bring this forward so that hopefully to have people do

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a better job of recognizing these very earliest warning signs that the child's

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actually in an environment that's not safe for them. I kind of liken it to lead

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poisoning, like if we actually had a child that we diagnosed lead poisoning

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on, we wouldn't fix the lead poisoning and send it back in the environment

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without figuring out what's going on. So certain bruises can actually be as

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significant as lead poisoning. In fact, we saw that children with, from physical

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abuse, had lower IQs in the future if we didn't intervene than did children that

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that were exposed to lead poisoning.

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So it's really critical to get this right early on

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and right away.

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- I really like these as screening tools

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that they're an easy way for us to screen

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in an evidence-based way for abuse

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in the emergency department.

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Now, these bruises, these injuries are not,

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does not equal abuse just because you see an air bruise.

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There might be a reasonable cause for it.

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It's just not normal.

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And when you look at the vast majority of kids, they don't get ear bruises with accidental

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play.

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And so it's a moment to be like, slow your roll.

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Let's ask some more questions.

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Let's look at this.

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You know, we've talked about this on previous podcast and you and I have worked together

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for years on this.

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So I feel very comfortable in the emergency department with this.

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This was studied in pediatric emergency departments across the United States.

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So we're good there.

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To me, this feels like an easy, validated tool to be able to use in the emergency department.

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yesterday, I spoke with one of our local sheriffs and he calls me and he's like, "Julia, I was just

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in at a conference in Dallas and they were talking about 10-4 FACESp. And I'm super excited to talk

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about this with my team further, but what should I do with this information? What do you want me

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as a sheriff to do with 10-4 FACESp?" And I thought it was a great question. Now I can tell

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you what I answered to him. But I would love to hear your advice for taking this data outside

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of the emergency department into the field. Or let's just even say a nonpediatric emergency

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department because that's who's listening to this podcast or a clinic. Can we take this

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and apply it in those settings? And can we and should we? How would we?

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That's a great question. You know, many of the patients that were in the study, often

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they came from primary care offices first, they came from general EDs very commonly before

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they made it to the referred to the children's hospitals. So a lot of the patients in the

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original study did come from general EDs. And a lot of the patients in the original study

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came from primary care settings. Some of them actually even came from social service offices

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or when parole officers or police had found a child. But it hasn't been truly validated

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in those groups. And so it's critical that as we're applying the tool and as we're noticing

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these things, that we realize that it was validated really and truly in a large population

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of pediatric patients that made it to a pediatric emergency department. I would love for studies

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to be done in primary care to test the rule, how does it work in primary care? And in general

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EDs, we're planning studies right now to expand it to general EDs. I have people call me from

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all over the world talking about how using the tool has helped them identify abuse victims

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that they would have missed otherwise.

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And so I'm excited to take it to the next step and to study it.

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I really like when you make your data available and people can see and think on their own.

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Like you said, it's not a diagnostic tool.

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It's not magic, but it's noticing it and then asking questions and does it make sense.

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And you're still the decider, you're the decision maker.

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It's just to help hopefully put some better evidence or stronger, more robust evidence

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in your hands to help inform your decision making.

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So what would you tell my sheriff colleague when he's like, "Okay, what am I supposed

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to do with this data?

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What should I tell my team to do with this information?"

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I would actually recommend that they use it with caution.

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But what's interesting is that once a police officer is already involved in evaluating

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a child, we already have a much higher concern.

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And one of the studies that inspired me to develop a recent clinical decision rule in

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the first place was a study of children that had fatal or near fatal abuse.

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And many of those cases had police officers or detectives that were involved in the initial

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evaluation or assessment of those children.

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And the rule literally worked unanimously in all of those patients.

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Of all the children that died, if the rule had been known and applied, it didn't exist

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then, but if it had been applied, 100% of those children could have potentially been

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identified and protected.

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You know?

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Yeah, that's really powerful.

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This rule applied to our patient that we talked about in the first podcast who had had subconjunctival

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hemorrhages over and over again, went to a pediatrician over and over again asking, "Is

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this normal?

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Does this make sense?

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I've never seen this in babies before."

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So it applied in our one case that we talked about too.

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Yeah, totally.

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So I remember years ago, like let's go back circa, I think it was like 2012 MCB.

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When we first talked about the validation of the 10.4 faces, or at that time it was

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just 10.4, and even then, just when smartphones were in their infancy, you had the vision

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to create an app that everyone could use, could put into their pocket to help them apply

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the 10.4 rule.

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I am super excited that that vision has been realized now, and you have an app that's called

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Elcast, right?

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Correct.

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Tell us about the app.

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Yeah, I'm super excited about this.

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The idea of wanting to have a visual, like a little 3D human where you could just touch

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on that human and it could actually indicate what you're seeing on the little 3D model

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that has data embedded in it so that it kind of takes out some of those steps of having

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to know what anatomy is and understand what you're seeing exactly.

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You just replicate what you're seeing on the 3D model.

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And what I'm super excited about is that it connects you with data from all of this research

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that we've done, so you can actually compare your patient to thousands of patients.

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And what's cool about that, the reason I'm especially excited about it is because the

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TIN4 FACES-P is almost like a, it's almost a binary answer, it's like you're more likely

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to be abuse or you're less likely to be abuse.

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Whereas the app allows you to look at every single region that we actually identified

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in the study and allows you to see how strong of a likelihood it is with that very specific

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finding.

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example, if you did, you know, angle of the jaw, you're going to get a likelihood ratio

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if you have that finding. Or if you have a back bruise, you're getting a likelihood ratio

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and you can actually even see in the data how many patients that were in the emergency

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department studies had that finding that were of use and how many were accident and then

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how many patients had that in all the patients that were studied. So it gives you two different

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lenses to look at the data with. And what I'm hoping is that allows the person to even

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think at a more complex level or a little, it gives you context to your thinking. So

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So if I see a baby that has, or let's say like a three-year-old that has angle of jaw

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bruising that's right along that edge there, if that's their only finding versus a three-year-old

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that has a back bruise, I'm going to feel very different about that angle of jaw bruising

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than I am a back bruise.

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Back bruise might occur, and you saw in the study or you can see in the data from the

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app, I think it was only 63% of the time it was abused, whereas angle of the jaw bruising

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was like 97 or 98% of the time it was abused.

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So it's not just, I'm excited because I want people to be able to have the data to think

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in a deeper way in a more complex way.

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So if it makes sense for your patient, great.

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If you have a three-year-old that's rambunctious, I don't want people to overstep or overreact.

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And it gives you the context to say, "You know what?

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I had a lot of patients that had this that was an abuse."

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Or vice versa.

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If you have an angle of the jaw, I mean, you should get nauseated when you see it, you

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know.

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Yeah.

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Yeah.

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And I love the idea of this app partly because I'm a very visual person.

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And then also because it's something I don't have to keep in my brain.

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But who do you see as the target user for this app?

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Who should have this on their phone?

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What I'm hoping is that everyone.

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What I'm hoping is that certainly those of us that are having to make decisions in the

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moment, that's who's going to be most helped with this, like the general ED physicians,

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APNs, nurses, people that are right there in the moment, social workers in investigative

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fields like social services.

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These are groups that we're actually testing the app in and putting it forth and seeing

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how they're interpreting the data, seeing how you're thinking about it.

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But those that have to make a decision in the moment, that's where if they at least

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have more data at the tips of their fingers, they're hopefully going to make a more informed

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decision.

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And we all know that nobody goes around reading all the literature all the time,

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and you certainly don't remember it.

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And so one of the goals also was to put evidence-based literature in the hands

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of a lot of people because we have links all through the app that take you to all

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kinds of articles, not just our own article, but take you to other articles

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to saying why we supported this, why it's in the app in the first place.

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So everything that's in the app has to be published first.

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The app in itself doesn't give you any recommendations.

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It just sells if something's more likely or not based on publications.

252
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So how do you recommend we use this?

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Should I be pulling it out on every kid

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that has a skin finding?

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- I have two goals.

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One is that people would use it

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when a child has skin findings.

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You know, if you have bruises, you know,

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like just pull it out.

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And if you have, if it makes sense, great, move on.

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If it doesn't make sense,

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you have a reason now to say,

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why I'm not gonna just ignore this.

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A second way I'm hoping people will use it

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is like remembering what to do and what to look for.

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In certain cases, especially those high risk signs

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or symptoms where most children that are abused

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actually present with a trauma complaint. So that's part of the problem, right? If we wait for a trauma

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patients to be the only ones we apply the app on or apply the 10-4-FACESp rule on, then we're going

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to miss abuse 80% of the time because most often babies and young children that are abused, they

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don't present with the trauma complaint, they present with the medical complaint like a

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fussiness, vomiting, seizure, ALTE. So one of the things I was hoping is that when you have like

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those high-risk complaints, people will actually pull out the app and remember, "Okay, I got to make

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make sure that that that frina is intact. I got to make sure that there's no

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sub-conductable humans and if there is don't just ignore it don't just say oh

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I'm sure that's just from vomiting because it is really not good evidence

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that an infant can generate enough force to have those kind of hemorrhages from

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just vomiting alone. So I just popped in a case that I had a couple of years ago

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on an infant that came in with an abdominal bruise and one of the things

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that's different about the app versus just the article

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or just the simple tool itself is that they're

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asking more questions about signs and symptoms.

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It's asking about the caregiver.

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It asks about is it patterned.

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There's just several more questions

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that kind of give some more nuance, I think,

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to the approach that you can't remember when

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you're making a simple rule like 10-4 FACESp is super easy,

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and it needs to be easy so we can all remember it.

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But this allows us to get a little bit more nuanced

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in our approach to this, and then gives us

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an abuse more likely yes or no type of situation.

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I also really like the bottom part.

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You scroll down until you see likelihood of abuse,

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and then possible next steps, and then what the AAP

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recommends for screening for occult children.

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And then you can click on the references,

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as you mentioned here.

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I think the possible next steps is

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one of my favorite parts about this app,

301
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because it empowers them to move on with,

302
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okay, I've already identified it.

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Now what do I do is the question

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that I think a lot of people ask me anyways,

305
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is like, okay, I got called last night

306
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about these kiddos that had bruises all over them.

307
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And the question was, now what?

308
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And so this gives this everybody access to everyone

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in their pockets, now what?

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(laughs)

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What do I do with this?

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- That's great.

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- So I like it.

314
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- I appreciate your bringing that up as well,

315
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because one of the hurdles that we face

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and trying to improve child abuse recognition

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is that people think that, for example,

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if the scalable survey is negative,

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therefore abuse is negative.

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And I hear this all the time.

321
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And so, you know, the next podcast we should do

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is like, when is a bruise enough?

323
00:17:53,060 --> 00:17:55,700
- Yeah, yeah, that's a great question.

324
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- What people don't realize is that the bruises are,

325
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you know, like you have your skin injuries,

326
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then you have your bone injuries,

327
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then you have your brain injury,

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and abdominal injuries,

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and each of those are independent thinking.

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You can put the whole puzzle together, of course,

331
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But just because you don't have a broken bone

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doesn't mean it's not abuse.

333
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And I wouldn't want people to think that.

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But over and over again, you hear people say,

335
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well, they had this weird bruising,

336
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but the skeletal surface is negative,

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so we didn't report.

338
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And it's like that's saying,

339
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well, you know, you were in a car crash,

340
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but you didn't break your leg,

341
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so I don't think you were in a car crash.

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- Right, right.

343
00:18:26,160 --> 00:18:27,480
So let's talk about that a little bit.

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The app does have the recommendations,

345
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but what do you recommend that physicians do

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when they see a 10-4 FACESp injury?

347
00:18:33,640 --> 00:18:35,800
- I mean, the most important thing

348
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to like context, context, context, right? Ask good questions and do a good exam and ask

349
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good questions. And if it makes sense, like if you have a child that has a frenulum injury,

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I mean, those occur accidentally. Of course, people can drop babies, you can get frenulum

351
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injuries. If the story makes sense and you don't have any other findings, it's the best

352
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we can do. But it's not the best we can do if we're not at least noticing those findings

353
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in the first place and asking the questions.

354
00:19:00,840 --> 00:19:03,160
What about the non-physician?

355
00:19:03,160 --> 00:19:07,600
Okay, so my colleague, the sheriff, downloads this app.

356
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These possible next steps are very medical piece.

357
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What would you recommend for, like, CPS or law enforcement for other people that are

358
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not directly having access to medical technology like we do?

359
00:19:21,040 --> 00:19:26,120
Yeah, I love the question because when we did our study on fatal and near-fatal abuse,

360
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a lot of those babies that died were never brought to medical care because social services

361
00:19:30,340 --> 00:19:36,100
investigating the child, maybe took the child to like a general ED where the person didn't

362
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have the knowledge about that.

363
00:19:37,540 --> 00:19:38,540
Of course, a lot of people did.

364
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It's not a criticism.

365
00:19:40,140 --> 00:19:44,740
Or sometimes they just decided it wasn't a big deal and just dismissed it on their own.

366
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So one of the things that if you have these findings and if you can look at the app and

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see that this is actually a high-risk bruise, you know, this is like if you had bilateral

368
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ear bruising, you know, or if you had bilateral cheek bruising or bilateral angle of jaw bruising,

369
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that's really a high risk.

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It's a very high-risk finding.

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So you wouldn't leave that...

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Paramedics, that's a good question for paramedics as well, like police officers, sheriffs, paramedics.

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They often are the first people in a home, and if they see these kind of marks on a child,

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they wouldn't leave them behind.

375
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They would bring them to a medical facility.

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And then I would be...

377
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It's just so important.

378
00:20:16,180 --> 00:20:18,980
I would be bold enough to say, "Hey, if they're saying, 'Oh, it's not a big deal,' say, 'Well,

379
00:20:18,980 --> 00:20:21,500
look at this app, and look at this data.'"

380
00:20:21,500 --> 00:20:24,780
I don't want to be contentious, but at the same time, we're really doing something really

381
00:20:24,780 --> 00:20:29,940
important here to try to identify children at risk, these very young, vulnerable children

382
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at risk.

383
00:20:30,940 --> 00:20:36,920
So you would say if somebody that's not in the medical field identifies one of these

384
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injuries, you would say get them in to see a physician to have this evaluation.

385
00:20:43,640 --> 00:20:47,480
And if you're a general pediatrician that sees this, like this is the moment to take

386
00:20:47,480 --> 00:20:51,520
it seriously, maybe send into the emergency department to get some of these injuries done

387
00:20:51,520 --> 00:20:57,240
or excuse me to get some of these studies done or do them yourself as an outpatient.

388
00:20:57,240 --> 00:20:58,240
Is that fair?

389
00:20:58,240 --> 00:20:59,240
Yeah, it is.

390
00:20:59,240 --> 00:21:04,340
And the other piece is that I can think of very specific stories where sheriffs had gone

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00:21:04,340 --> 00:21:07,440
to homes because of a domestic violence call.

392
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And if you want to see where we've really got big risk, it's we're in homes of domestic

393
00:21:11,040 --> 00:21:14,440
violence for sure, because violence, it overbleeds onto the children.

394
00:21:14,440 --> 00:21:18,160
And just because, you know, I don't know why people don't realize that, but a lot of people

395
00:21:18,160 --> 00:21:21,640
don't realize how dangerous it is for a child to be in a home where domestic violence is

396
00:21:21,640 --> 00:21:22,960
occurring.

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00:21:22,960 --> 00:21:27,680
And I remember one story where they noticed that the young child, a very young child,

398
00:21:27,680 --> 00:21:31,280
had a black eye and they were responding to a domestic violence.

399
00:21:31,280 --> 00:21:35,320
So that's an example of just your ability to observe what else is going on.

400
00:21:35,320 --> 00:21:38,640
Even if you would go to the home for a totally different reason and you see something like

401
00:21:38,640 --> 00:21:42,360
that, then you wouldn't leave that story behind.

402
00:21:42,360 --> 00:21:48,180
would bring that child for care to see if they're okay or see what's up, you know.

403
00:21:48,180 --> 00:21:54,380
So where do we go from here? Do you have a future vision for 10/4 faces P?

404
00:21:54,380 --> 00:22:00,100
So I'm excited that we are continuing to test it and validate it in different groups,

405
00:22:00,100 --> 00:22:05,500
General AEDs, Primary Care, Social Services, those are the three, and Paramedics, those

406
00:22:05,500 --> 00:22:11,460
are the four big groups that we're looking to do further evaluations in and see how people

407
00:22:11,460 --> 00:22:14,820
interpret the data, you know, because we all look at things and you think that

408
00:22:14,820 --> 00:22:17,180
it's going to be, we're all going to see the same thing we don't, you know, so how

409
00:22:17,180 --> 00:22:20,040
do we interpret the data, how do we make sure the data gets interpreted and used

410
00:22:20,040 --> 00:22:24,540
correctly, not overused or incorrectly used. That's one of the things, but the

411
00:22:24,540 --> 00:22:27,600
another thing I'm excited about is the app, this is hopefully just the

412
00:22:27,600 --> 00:22:32,140
beginning, I want the app to be an injury plausibility app, so then we actually, you

413
00:22:32,140 --> 00:22:36,000
may not know it, but the app already has a link to a head injury calculator in

414
00:22:36,000 --> 00:22:39,380
there that gives you probability for abuse, so it already has from Kent

415
00:22:39,380 --> 00:22:44,780
Emils work and the study he did was also NIH funded studies and so there's already a clinical

416
00:22:44,780 --> 00:22:48,320
decision rule in there for head injury which is pretty cool.

417
00:22:48,320 --> 00:22:52,140
But ultimately we'll actually also put our fracture injury plausibility model in there

418
00:22:52,140 --> 00:22:56,500
so we will have a little 3D skeleton just like we have a little 3D human and ultimately

419
00:22:56,500 --> 00:23:00,760
I wanted to, we already have it built in the back end, we're just turning things on as

420
00:23:00,760 --> 00:23:02,920
we get the data to populate it.

421
00:23:02,920 --> 00:23:08,020
We'll be able to have all injuries that you see and do, click on them all so that you

422
00:23:08,020 --> 00:23:12,220
You can have a transparent feature and you can see them all at once and then it'll give

423
00:23:12,220 --> 00:23:17,260
you an injured plausibility model, calculations for all that you see, and then for individual

424
00:23:17,260 --> 00:23:18,260
things that you're seeing.

425
00:23:18,260 --> 00:23:25,340
That is so slick because, you know, I often have these conversations with CBS, law enforcement,

426
00:23:25,340 --> 00:23:31,020
DAs, you know, county council, all these people about like, how sure are you that this is

427
00:23:31,020 --> 00:23:32,020
abuse?

428
00:23:32,020 --> 00:23:37,500
And to be able to have these numbers with accumulative injuries would just be incredibly

429
00:23:37,500 --> 00:23:39,100
fantastic, so informative.

430
00:23:39,100 --> 00:23:41,660
Yeah, and Julia, I mean, this is not my specialty.

431
00:23:41,660 --> 00:23:46,660
I am general emergency medicine, so I have way less expertise than either of you.

432
00:23:46,660 --> 00:23:52,740
And I love this because I don't always know what is a concerning injury and then what

433
00:23:52,740 --> 00:23:54,860
the next steps are and all of this.

434
00:23:54,860 --> 00:23:59,540
So to be able to put this all together in an easy app and to get an answer and some

435
00:23:59,540 --> 00:24:02,580
recommendations, I think it's amazing.

436
00:24:02,580 --> 00:24:07,460
Before we go, you mentioned the Fracture Plasibility Study, and I'm super honored to play a really

437
00:24:07,460 --> 00:24:13,740
very small role in that, but I want to get people pumped up and excited about it. They

438
00:24:13,740 --> 00:24:18,140
may not be quite as excited as I am, but I want to get people excited about this. Tell

439
00:24:18,140 --> 00:24:23,340
us briefly what this next project is and how this is going to change the way that we look

440
00:24:23,340 --> 00:24:26,020
at injured children.

441
00:24:26,020 --> 00:24:30,620
So it actually just combines like very basic things that we all should be doing when we're

442
00:24:30,620 --> 00:24:34,420
actually evaluating patients or things that you're already doing. Your history, you're

443
00:24:34,420 --> 00:24:38,820
thinking about does an injury match or not and noticing the timing, does it make sense

444
00:24:38,820 --> 00:24:41,540
with a delay or not a delay, does it make sense?

445
00:24:41,540 --> 00:24:45,360
And then incorporating that last point into what's the skin finding because everybody

446
00:24:45,360 --> 00:24:47,780
often overlooks the skin finding.

447
00:24:47,780 --> 00:24:53,240
So having a model that helps you see the likelihood of a fracture being from abuse or not or having

448
00:24:53,240 --> 00:24:56,240
a head injury from being abuse or not, like those are where the models are going in the

449
00:24:56,240 --> 00:25:00,000
future, just that in itself I think can actually help.

450
00:25:00,000 --> 00:25:03,880
But another thing I'm super excited about, and I'm glad you brought this back up, is

451
00:25:03,880 --> 00:25:08,280
that already in the testing that we've done in the current study we have and in the past

452
00:25:08,280 --> 00:25:14,080
studies we've done, when we applied the model, we were able to see we would have theoretically

453
00:25:14,080 --> 00:25:18,240
decreased racial bias and disparity in decision making that was being made.

454
00:25:18,240 --> 00:25:22,600
Because when you applied the model, it predicted that it wasn't abuse and it turned out to

455
00:25:22,600 --> 00:25:26,360
not be abuse, but many of those children ended up having skeletal surveys or reporting to

456
00:25:26,360 --> 00:25:28,920
social services, that kind of thing.

457
00:25:28,920 --> 00:25:34,160
And it was much more likely to have occurred in black children and Hispanic children and

458
00:25:34,160 --> 00:25:35,320
Native American children.

459
00:25:35,320 --> 00:25:41,280
And so if we have that situation, how exciting is it that an objective tool could potentially

460
00:25:41,280 --> 00:25:46,320
help us all apply a more equitable decision making?

461
00:25:46,320 --> 00:25:47,320
That's the ultimate goal.

462
00:25:47,320 --> 00:25:48,320
You know?

463
00:25:48,320 --> 00:25:50,360
I think that's going to be another great podcast.

464
00:25:50,360 --> 00:25:55,520
We'll bring you and Dr. Johnson on for that discussion because that's going to be fantastic.

465
00:25:55,520 --> 00:26:01,040
And I think we need to regroup once we have the fracture plausibility rule set up because

466
00:26:01,040 --> 00:26:03,960
that is going to be super exciting as well.

467
00:26:03,960 --> 00:26:09,720
So MCP, thank you for all that you do to help us in the emergency department on every shift

468
00:26:09,720 --> 00:26:12,080
and also to protect injured kiddos.

469
00:26:12,080 --> 00:26:17,000
I love that you are constantly thinking of new ways to make it easier for all of us to

470
00:26:17,000 --> 00:26:19,240
identify non-accidental trauma.

471
00:26:19,240 --> 00:26:21,440
And I can't wait to talk about this more with you.

472
00:26:21,440 --> 00:26:22,440
So thank you.

473
00:26:22,440 --> 00:26:23,760
Thanks for having such an awesome podcast.

474
00:26:23,760 --> 00:26:25,200
I enjoy your podcast so much.

475
00:26:25,200 --> 00:26:27,200
Aww, thank you!

476
00:26:27,200 --> 00:26:35,200
[Music]

477
00:26:36,200 --> 00:26:38,200
[Music ends]

478
00:26:39,200 --> 00:26:41,200
[Music ends]

479
00:26:42,200 --> 00:26:44,200
[Music ends]

480
00:26:44,200 --> 00:26:46,200
ri

481
00:26:46,200 --> 00:27:07,100
According to a hadnaean