Hi there! Real quick before we start the podcast, I want to recognize today is October 4, 2023, as in 10/4. 10/4 is the acronym for concerning injuries that MCP, Mary Clyde Pierce, and her team created. So, on October 4, many states used this as a moment to spread the "10/4" message, and we at EM Pulse agree. We want to share a special resource that you can use in your practice to identify skin injuries in kids that may point to abuse.
Also, the EIIC, or Emergency Medical Services for Children Innovation and Improvement Center, has created another wonderful PEAK. A PEAK is a pediatric education and advocacy kit, and this one is focused on child abuse for emergency departments. The goal of these peaks is to help clinicians identify and care for abused children in emergency departments. And this podcast is a part of that toolkit. So, check it out at emscimprovement.center or check out the link with inside of our notes.
All right, now let's get started with our podcast. This is EM Pulse with your hosts, Sarah Medeiros and Julia Magaña. Welcome back to EM Pulse. On March 17, 2023, we replayed or repeated the powerful podcast, "It Could Have Been Different". That podcast reviewed the work of Dr. Mary Clyde Pierce, my friend and mentor. We heard the story of a nurse whose child was abused and the opportunities the medical community had to prevent the severe abuse the child endured.
We also heard from Dr. Pierce about the simple tool 10-4 FACESp that we can use in the emergency department setting to screen for concerning injuries in children less than four years of age. Now, we are back with MCP again with an update on 10-4 FACESp. Now remember, Dr. Mary Clyde Pierce is a pediatric emergency medicine physician, child abuse injury researcher, and professor of pediatric emergency medicine and preventive medicine at Northwestern University Feinberg School of Medicine.
Welcome back, MCP! Woo hoo! I am excited to talk about this again because there are some really important updates to this body of work. So let's get into this. So let's walk through the acronym for 10-4 FACESp. What does that stand for? Yeah, okay. So let's do the regions first and then we'll do what the number in the P stands for. So the regions are 10 and faces stands for regions on the body that were predictive of abuse versus an accidental injury.
So T stands for torso, which is really basically your chest, abdomen, back and buttocks. So you should trunk. So T stands for torso, E stands for ear, either of them or both. N stands for neck. F stands for the frenulum and you have three of them in your mouth, the upper gum, the lower gum and then under your tongue. A stands for angle of jaw. That was a very interesting finding. So A stands for angle of jaw.
C stands for cheek, but the fleshy part, you know, the part that's that little cute part that's right by your mouth and not the hard part that's up below your eye. So the fleshy part of your cheek. E stands for eyelids. And then S stands for subconjectiva. So when your subconjectiva have a hemorrhage, it's a very red appearance. And then P stands for pattern. So any kind of pattern like a loop mark or linear marks. And then the four actually has kind of a double meeting.
First off, the rule only applies to children that are under four years of age. But importantly, our studies show that any bruising anywhere on infants that are four months of age and younger. So if you're four and a half months age, any bruise anywhere, it was actually predictive of abuse. So any bruise anywhere for infants that are four months, 4.99 months literally, and younger, predicted abuse. I love the simplicity of this.
And we were just talking before the podcast started that I was using this rule earlier today on a consult that I was doing in the emergency department. But MCP remind us, what is the significance of injuries in these areas? What does this mean? Why is this important? - The whole passion began by trying to figure out and identify abuse very early on.
And what we see over and over again, that, you know, like we said in our previous podcast, bruises are often dismissed as unimportant injuries and medically they may not typically are usually, they're not really that important, but when they tell you a story, the bruises actually tell you a story.
And in fact, the research we've been doing recently with fractures that you're helping us with and also our bruising research and our head injury research, what's interesting is that bruises seem to be a hallmark of a more violent form of abuse. So when you see bruises, you actually need to get extra concern, which is really interesting. We had more fatalities in our bruising study than other studies. So it's a marker of possibly even a more dangerous or severe environment.
But of course bruises occur from both accidental and abusive trauma. So it's really based on the principle that when somebody physically attacks a child, they go for very specific regions. There's some kind of like primal thing inside humans where they attack them around the neck or around the mouth or around the abdomen. And those areas are hit them on the side of the head. So those areas over and over again kept predicting abuse.
And so that's why we wanted to bring this forward so that hopefully to have people do a better job of recognizing these very earliest warning signs that the child's actually in an environment that's not safe for them. I kind of liken it to lead poisoning, like if we actually had a child that we diagnosed lead poisoning on, we wouldn't fix the lead poisoning and send it back in the environment without figuring out what's going on. So certain bruises can actually be as
significant as lead poisoning. In fact, we saw that children with, from physical abuse, had lower IQs in the future if we didn't intervene than did children that that were exposed to lead poisoning. So it's really critical to get this right early on and right away. - I really like these as screening tools that they're an easy way for us to screen in an evidence-based way for abuse in the emergency department.
Now, these bruises, these injuries are not, does not equal abuse just because you see an air bruise. There might be a reasonable cause for it. It's just not normal. And when you look at the vast majority of kids, they don't get ear bruises with accidental play. And so it's a moment to be like, slow your roll. Let's ask some more questions. Let's look at this. You know, we've talked about this on previous podcast and you and I have worked together for years on this.
So I feel very comfortable in the emergency department with this. This was studied in pediatric emergency departments across the United States. So we're good there. To me, this feels like an easy, validated tool to be able to use in the emergency department. yesterday, I spoke with one of our local sheriffs and he calls me and he's like, "Julia, I was just in at a conference in Dallas and they were talking about 10-4 FACESp. And I'm super excited to talk
about this with my team further, but what should I do with this information? What do you want me as a sheriff to do with 10-4 FACESp?" And I thought it was a great question. Now I can tell you what I answered to him. But I would love to hear your advice for taking this data outside of the emergency department into the field. Or let's just even say a nonpediatric emergency department because that's who's listening to this podcast or a clinic. Can we take this
and apply it in those settings? And can we and should we? How would we? That's a great question. You know, many of the patients that were in the study, often they came from primary care offices first, they came from general EDs very commonly before they made it to the referred to the children's hospitals. So a lot of the patients in the original study did come from general EDs. And a lot of the patients in the original study
came from primary care settings. Some of them actually even came from social service offices or when parole officers or police had found a child. But it hasn't been truly validated in those groups. And so it's critical that as we're applying the tool and as we're noticing these things, that we realize that it was validated really and truly in a large population of pediatric patients that made it to a pediatric emergency department. I would love for studies
to be done in primary care to test the rule, how does it work in primary care? And in general EDs, we're planning studies right now to expand it to general EDs. I have people call me from all over the world talking about how using the tool has helped them identify abuse victims that they would have missed otherwise. And so I'm excited to take it to the next step and to study it. I really like when you make your data available and people can see and think on their own.
Like you said, it's not a diagnostic tool. It's not magic, but it's noticing it and then asking questions and does it make sense. And you're still the decider, you're the decision maker. It's just to help hopefully put some better evidence or stronger, more robust evidence in your hands to help inform your decision making. So what would you tell my sheriff colleague when he's like, "Okay, what am I supposed to do with this data?
What should I tell my team to do with this information?" I would actually recommend that they use it with caution. But what's interesting is that once a police officer is already involved in evaluating a child, we already have a much higher concern. And one of the studies that inspired me to develop a recent clinical decision rule in the first place was a study of children that had fatal or near fatal abuse.
And many of those cases had police officers or detectives that were involved in the initial evaluation or assessment of those children. And the rule literally worked unanimously in all of those patients. Of all the children that died, if the rule had been known and applied, it didn't exist then, but if it had been applied, 100% of those children could have potentially been identified and protected. You know? Yeah, that's really powerful.
This rule applied to our patient that we talked about in the first podcast who had had subconjunctival hemorrhages over and over again, went to a pediatrician over and over again asking, "Is this normal? Does this make sense? I've never seen this in babies before." So it applied in our one case that we talked about too. Yeah, totally. So I remember years ago, like let's go back circa, I think it was like 2012 MCB.
When we first talked about the validation of the 10.4 faces, or at that time it was just 10.4, and even then, just when smartphones were in their infancy, you had the vision to create an app that everyone could use, could put into their pocket to help them apply the 10.4 rule. I am super excited that that vision has been realized now, and you have an app that's called Elcast, right? Correct. Tell us about the app. Yeah, I'm super excited about this.
The idea of wanting to have a visual, like a little 3D human where you could just touch on that human and it could actually indicate what you're seeing on the little 3D model that has data embedded in it so that it kind of takes out some of those steps of having to know what anatomy is and understand what you're seeing exactly. You just replicate what you're seeing on the 3D model.
And what I'm super excited about is that it connects you with data from all of this research that we've done, so you can actually compare your patient to thousands of patients. And what's cool about that, the reason I'm especially excited about it is because the TIN4 FACES-P is almost like a, it's almost a binary answer, it's like you're more likely to be abuse or you're less likely to be abuse.
Whereas the app allows you to look at every single region that we actually identified in the study and allows you to see how strong of a likelihood it is with that very specific finding. example, if you did, you know, angle of the jaw, you're going to get a likelihood ratio
if you have that finding. Or if you have a back bruise, you're getting a likelihood ratio and you can actually even see in the data how many patients that were in the emergency department studies had that finding that were of use and how many were accident and then how many patients had that in all the patients that were studied. So it gives you two different lenses to look at the data with. And what I'm hoping is that allows the person to even
think at a more complex level or a little, it gives you context to your thinking. So So if I see a baby that has, or let's say like a three-year-old that has angle of jaw bruising that's right along that edge there, if that's their only finding versus a three-year-old that has a back bruise, I'm going to feel very different about that angle of jaw bruising than I am a back bruise.
Back bruise might occur, and you saw in the study or you can see in the data from the app, I think it was only 63% of the time it was abused, whereas angle of the jaw bruising was like 97 or 98% of the time it was abused. So it's not just, I'm excited because I want people to be able to have the data to think in a deeper way in a more complex way. So if it makes sense for your patient, great. If you have a three-year-old that's rambunctious, I don't want people to overstep or overreact.
And it gives you the context to say, "You know what? I had a lot of patients that had this that was an abuse." Or vice versa. If you have an angle of the jaw, I mean, you should get nauseated when you see it, you know. Yeah. Yeah. And I love the idea of this app partly because I'm a very visual person. And then also because it's something I don't have to keep in my brain. But who do you see as the target user for this app? Who should have this on their phone? What I'm hoping is that everyone.
What I'm hoping is that certainly those of us that are having to make decisions in the moment, that's who's going to be most helped with this, like the general ED physicians, APNs, nurses, people that are right there in the moment, social workers in investigative fields like social services. These are groups that we're actually testing the app in and putting it forth and seeing how they're interpreting the data, seeing how you're thinking about it.
But those that have to make a decision in the moment, that's where if they at least have more data at the tips of their fingers, they're hopefully going to make a more informed decision. And we all know that nobody goes around reading all the literature all the time, and you certainly don't remember it.
And so one of the goals also was to put evidence-based literature in the hands of a lot of people because we have links all through the app that take you to all kinds of articles, not just our own article, but take you to other articles to saying why we supported this, why it's in the app in the first place. So everything that's in the app has to be published first. The app in itself doesn't give you any recommendations. It just sells if something's more likely or not based on publications.
So how do you recommend we use this? Should I be pulling it out on every kid that has a skin finding? - I have two goals. One is that people would use it when a child has skin findings. You know, if you have bruises, you know, like just pull it out. And if you have, if it makes sense, great, move on. If it doesn't make sense, you have a reason now to say, why I'm not gonna just ignore this. A second way I'm hoping people will use it is like remembering what to do and what to look for.
In certain cases, especially those high risk signs or symptoms where most children that are abused actually present with a trauma complaint. So that's part of the problem, right? If we wait for a trauma patients to be the only ones we apply the app on or apply the 10-4-FACESp rule on, then we're going to miss abuse 80% of the time because most often babies and young children that are abused, they don't present with the trauma complaint, they present with the medical complaint like a
fussiness, vomiting, seizure, ALTE. So one of the things I was hoping is that when you have like those high-risk complaints, people will actually pull out the app and remember, "Okay, I got to make
make sure that that that frina is intact. I got to make sure that there's no sub-conductable humans and if there is don't just ignore it don't just say oh I'm sure that's just from vomiting because it is really not good evidence that an infant can generate enough force to have those kind of hemorrhages from
just vomiting alone. So I just popped in a case that I had a couple of years ago on an infant that came in with an abdominal bruise and one of the things that's different about the app versus just the article or just the simple tool itself is that they're asking more questions about signs and symptoms. It's asking about the caregiver. It asks about is it patterned.
There's just several more questions that kind of give some more nuance, I think, to the approach that you can't remember when you're making a simple rule like 10-4 FACESp is super easy, and it needs to be easy so we can all remember it. But this allows us to get a little bit more nuanced in our approach to this, and then gives us an abuse more likely yes or no type of situation. I also really like the bottom part.
You scroll down until you see likelihood of abuse, and then possible next steps, and then what the AAP recommends for screening for occult children. And then you can click on the references, as you mentioned here. I think the possible next steps is one of my favorite parts about this app, because it empowers them to move on with, okay, I've already identified it.
Now what do I do is the question that I think a lot of people ask me anyways, is like, okay, I got called last night about these kiddos that had bruises all over them. And the question was, now what? And so this gives this everybody access to everyone in their pockets, now what? (laughs) What do I do with this? - That's great. - So I like it.
- I appreciate your bringing that up as well, because one of the hurdles that we face and trying to improve child abuse recognition is that people think that, for example, if the scalable survey is negative, therefore abuse is negative. And I hear this all the time. And so, you know, the next podcast we should do is like, when is a bruise enough? - Yeah, yeah, that's a great question.
- What people don't realize is that the bruises are, you know, like you have your skin injuries, then you have your bone injuries, then you have your brain injury, and abdominal injuries, and each of those are independent thinking. You can put the whole puzzle together, of course, But just because you don't have a broken bone doesn't mean it's not abuse. And I wouldn't want people to think that.
But over and over again, you hear people say, well, they had this weird bruising, but the skeletal surface is negative, so we didn't report. And it's like that's saying, well, you know, you were in a car crash, but you didn't break your leg, so I don't think you were in a car crash. - Right, right. So let's talk about that a little bit. The app does have the recommendations, but what do you recommend that physicians do when they see a 10-4 FACESp injury? - I mean, the most important thing
to like context, context, context, right? Ask good questions and do a good exam and ask good questions. And if it makes sense, like if you have a child that has a frenulum injury, I mean, those occur accidentally. Of course, people can drop babies, you can get frenulum injuries. If the story makes sense and you don't have any other findings, it's the best we can do. But it's not the best we can do if we're not at least noticing those findings in the first place and asking the questions.
What about the non-physician? Okay, so my colleague, the sheriff, downloads this app. These possible next steps are very medical piece. What would you recommend for, like, CPS or law enforcement for other people that are not directly having access to medical technology like we do?
Yeah, I love the question because when we did our study on fatal and near-fatal abuse, a lot of those babies that died were never brought to medical care because social services investigating the child, maybe took the child to like a general ED where the person didn't have the knowledge about that. Of course, a lot of people did. It's not a criticism. Or sometimes they just decided it wasn't a big deal and just dismissed it on their own.
So one of the things that if you have these findings and if you can look at the app and see that this is actually a high-risk bruise, you know, this is like if you had bilateral ear bruising, you know, or if you had bilateral cheek bruising or bilateral angle of jaw bruising, that's really a high risk. It's a very high-risk finding. So you wouldn't leave that... Paramedics, that's a good question for paramedics as well, like police officers, sheriffs, paramedics.
They often are the first people in a home, and if they see these kind of marks on a child, they wouldn't leave them behind. They would bring them to a medical facility. And then I would be... It's just so important.
I would be bold enough to say, "Hey, if they're saying, 'Oh, it's not a big deal,' say, 'Well, look at this app, and look at this data.'" I don't want to be contentious, but at the same time, we're really doing something really important here to try to identify children at risk, these very young, vulnerable children at risk. So you would say if somebody that's not in the medical field identifies one of these injuries, you would say get them in to see a physician to have this evaluation.
And if you're a general pediatrician that sees this, like this is the moment to take it seriously, maybe send into the emergency department to get some of these injuries done or excuse me to get some of these studies done or do them yourself as an outpatient. Is that fair? Yeah, it is. And the other piece is that I can think of very specific stories where sheriffs had gone to homes because of a domestic violence call.
And if you want to see where we've really got big risk, it's we're in homes of domestic violence for sure, because violence, it overbleeds onto the children. And just because, you know, I don't know why people don't realize that, but a lot of people don't realize how dangerous it is for a child to be in a home where domestic violence is occurring. And I remember one story where they noticed that the young child, a very young child, had a black eye and they were responding to a domestic violence.
So that's an example of just your ability to observe what else is going on. Even if you would go to the home for a totally different reason and you see something like that, then you wouldn't leave that story behind. would bring that child for care to see if they're okay or see what's up, you know. So where do we go from here? Do you have a future vision for 10/4 faces P?
So I'm excited that we are continuing to test it and validate it in different groups, General AEDs, Primary Care, Social Services, those are the three, and Paramedics, those are the four big groups that we're looking to do further evaluations in and see how people interpret the data, you know, because we all look at things and you think that it's going to be, we're all going to see the same thing we don't, you know, so how
do we interpret the data, how do we make sure the data gets interpreted and used
correctly, not overused or incorrectly used. That's one of the things, but the another thing I'm excited about is the app, this is hopefully just the beginning, I want the app to be an injury plausibility app, so then we actually, you may not know it, but the app already has a link to a head injury calculator in there that gives you probability for abuse, so it already has from Kent Emils work and the study he did was also NIH funded studies and so there's already a clinical
decision rule in there for head injury which is pretty cool. But ultimately we'll actually also put our fracture injury plausibility model in there so we will have a little 3D skeleton just like we have a little 3D human and ultimately I wanted to, we already have it built in the back end, we're just turning things on as we get the data to populate it.
We'll be able to have all injuries that you see and do, click on them all so that you You can have a transparent feature and you can see them all at once and then it'll give you an injured plausibility model, calculations for all that you see, and then for individual things that you're seeing. That is so slick because, you know, I often have these conversations with CBS, law enforcement, DAs, you know, county council, all these people about like, how sure are you that this is abuse?
And to be able to have these numbers with accumulative injuries would just be incredibly fantastic, so informative. Yeah, and Julia, I mean, this is not my specialty. I am general emergency medicine, so I have way less expertise than either of you. And I love this because I don't always know what is a concerning injury and then what the next steps are and all of this. So to be able to put this all together in an easy app and to get an answer and some recommendations, I think it's amazing.
Before we go, you mentioned the Fracture Plasibility Study, and I'm super honored to play a really very small role in that, but I want to get people pumped up and excited about it. They may not be quite as excited as I am, but I want to get people excited about this. Tell us briefly what this next project is and how this is going to change the way that we look at injured children. So it actually just combines like very basic things that we all should be doing when we're
actually evaluating patients or things that you're already doing. Your history, you're thinking about does an injury match or not and noticing the timing, does it make sense with a delay or not a delay, does it make sense? And then incorporating that last point into what's the skin finding because everybody often overlooks the skin finding.
So having a model that helps you see the likelihood of a fracture being from abuse or not or having a head injury from being abuse or not, like those are where the models are going in the future, just that in itself I think can actually help.
But another thing I'm super excited about, and I'm glad you brought this back up, is that already in the testing that we've done in the current study we have and in the past studies we've done, when we applied the model, we were able to see we would have theoretically decreased racial bias and disparity in decision making that was being made.
Because when you applied the model, it predicted that it wasn't abuse and it turned out to not be abuse, but many of those children ended up having skeletal surveys or reporting to social services, that kind of thing. And it was much more likely to have occurred in black children and Hispanic children and Native American children. And so if we have that situation, how exciting is it that an objective tool could potentially help us all apply a more equitable decision making?
That's the ultimate goal. You know? I think that's going to be another great podcast. We'll bring you and Dr. Johnson on for that discussion because that's going to be fantastic. And I think we need to regroup once we have the fracture plausibility rule set up because that is going to be super exciting as well. So MCP, thank you for all that you do to help us in the emergency department on every shift and also to protect injured kiddos.
I love that you are constantly thinking of new ways to make it easier for all of us to identify non-accidental trauma. And I can't wait to talk about this more with you. So thank you. Thanks for having such an awesome podcast. I enjoy your podcast so much. Aww, thank you! [Music] [Music ends] [Music ends] [Music ends] ri According to a hadnaean