Sentinel Injuries

Dr. James Metz and Tracey Wagner, Forensic RN  from the University of Vermont’s Child Safe Program talks with Cassie Gillespie about sentinel injures on children and TEN-4.


Cassie Gillespie  (00:03):

Hi, I’m your host, Cassie Gillespie, and you’re listening to Welcome to The Field. A podcast of targeted training for child welfare workers, caregivers, and professionals.

Cassie Gillespie  (00:12):

Today. I’m super excited to bring you an episode where we’re going to talk about sentinel injuries and bruising. We’re going to talk with Dr. James Metz and Forensic Nurse, Tracy Wagner from UVM Medical Center’s Child Safe Program. And as always, we just want to let you know that due to these very odd times in the late spring and early summer of 2020, we’re recording from our homes due to COVID-19. So if it sounds like we’re all sitting in different rooms, that’s because we are. All right, so let’s get started. Welcome James and Tracy. Thanks for joining us today. We’re so happy to have you let’s start just with the basics. James, would you mind telling us a little bit about the Child Safe Program and your title and your background and how you got there?

Dr. James Metz (01:00):

Sure. Good morning. The Child Safe Program here at the University of Vermont has been around for several years. And I came to the program about a year and a half ago from Seattle where I was doing my pediatric training and specifically child abuse training. I work here in the hospital with both Tracy and a Social Worker, Mary Ellen, and we work both with patients here in the hospital, as well as patients around the state to help in protecting children and diagnosing child abuse around the state.

Cassie Gillespie  (01:48):

And you’re originally from Vermont, right? Is this a homecoming for you to come back here?

Dr. James Metz (01:54):

I originally am from Shelburne and was in Seattle for 12 years and happily came back.

Cassie Gillespie  (02:01):

We’re so glad you did. All right, Tracy, would you mind telling us a little bit about your career trajectory and how you got connected with the child safe program?

Tracey Wagner (02:12):

Okay. Well, I have been a pediatric nurse, my entire career, I worked at UVM children’s hospital and worked in some inpatient, outpatient pediatric high-tech home visiting nursing as well and became a foster parent about 25, 30 years ago. And also did some work at the time with the UVM social work program working as an advisor for social work students who were learning about kids with special needs. And about 10 years ago or so was asked by Dr. Patno, and the emergency department who began developing a child sexual abuse response in the emergency room. I was interested in that and here I am today, 10 years later, I have helped Dr. Hagan a little bit as we ran the, it began starting a child abuse program at the University of Vermont Medical Center. So for folks who are either new to the topic, or just need a refresher, would you mind telling us what are sentinel injuries?

Dr. James Metz (03:26):

Sure. Sentinal injuries mean different things to different people, but in general sentinel injuries are those injuries in children that are harbinger’s of worse injuries. So for instance we often think of bruising as a sentinel injury. So a small bruise on a child that is two weeks old would be considered a sentinel injury or a small cut of the frenulum of a child would be considered a sentinel injury.

Cassie Gillespie  (04:07):

You may have to tell us what a frenulum is.

Dr. James Metz (04:10):

Sure. A frenulum is that little piece of skin underneath the tongue that sometimes gets clipped. If people have a tongue tied, little children have tongue ties, they sometimes clip that to help with breastfeeding. So they’re the injuries that oftentimes keep me awake at night because they often get missed. And if they get missed, then the child potentially goes home and suffers worse injuries in the future.

Cassie Gillespie  (04:42):

Okay. I know we’re going to get into it and in a little bit, but I’m curious right now, so how might the injury to the frenulum be an indicator of something more sinister or something more impactful?

Dr. James Metz (04:57):

Sure. Any injury on a child that has a poor explanation or really is unusual is concerning and it has to be explained. And so when we see an injury such as a torn frenulum in a child, we look for how that could happen. And there are only a few reasons why a small child should have an injury to their frenulum or a small bruise on their cheek or on their torso. And those should have a good explanation for them. And if they don’t then we need to pursue it further and make sure that the child is safe. And so when we see those injuries, we take note and think about other injuries that could go along with that. So for instance, a torn frenulum could be from force feeding a child, or using an implement in the child’s mouth out of frustration or for whatever reason, and could be an indicator of worse injuries to the back of the throat or to the head or something else. So we think about it in the context of the health of the overall wellbeing of the child.

Cassie Gillespie  (06:19):

Okay. That’s helpful. Thank you. So having done front end work myself in the past, I know that there are certain injuries that you really want to pay attention to, and also being the mom of a toddler who is currently covered in bruises from, you know, her knees to her toes and her elbows to her fingers. Is there any way to help us kind of remember or keep track of what is concerning and what is developmentally normative?

Dr. James Metz (06:47):

Yeah, it’s a great question. And I hope that people don’t come away from this thinking that every time there’s a bruise on a child, they have to think about child abuse because that’s far from the case. In fact when I see children in the hospital or outside the hospital and with bruises on them in the right location, it’s encouraging to me, it means that they’re outside playing climbing trees, doing what they should be doing and maybe not spending so much time in front of the computer or the screen. But there are bruises that are concerning and that we can’t overlook. And there’s a few ways to remember them really easily. And they’re based on science, they’re based on good literature. And the two ways that I remember it and teach two are this the first one is the expression, those who don’t cruise rarely bruise.

Cassie Gillespie  (07:46):

Okay. Tell us what that means.

Dr. James Metz (07:48):

So what that means is children who aren’t cruising, who aren’t mobile. Don’t bruise very often, and we know that from looking at children in clinics, when they come in for a regular well child visits, we look at their skin. And most of them, if they’re just infants, don’t have bruises on them. And once they start ambulating children start moving around, crawling around getting up to stand, walk, run. Then there are certain patterns of bruises or locations on the body that we expect bruises to be more often.

Cassie Gillespie  (08:26):

Okay. Thanks. Tracy, do you want to tell us a little bit more about TEN-4 bruising in particular?

Tracey Wagner (08:32):

Okay. There was some good research done a few years ago and it’s a clinical decision making tool. So it’s one tool that you can use, but it’s validated, it’s got good research behind it, and it’s almost always accurate and true, TEN-4 is the old CB code for okay, good buddy. And it’s an acronym. So it’s the T itself and you can write this down sometimes it’s very helpful. So if you’ve got a pen and paper, you can write down T, T stands for torso, and that’s the area between your shoulders and your hips. So it includes your genitals and includes buttocks. That’s a pretty big expanse for kids. So torso from shoulders to hips E stands for ears and stands for neck. And so that’s torso ears, neck, TEN, the 4 reminds us that any bruises in any child under the age of four months are those that we should be worried about. And any bruises in the 10 region for children under the age of four years are the ones we should be worried about. So TEN-4 is an easy way to think about bruises that are concerning.

Cassie Gillespie  (09:54):

That’s super helpful.

Tracey Wagner (09:56):

Any bruises on any child under the age of four, because they’re very immobile and rely on caregivers for positioning and safety, and then bruises in that 10 region for kids under the age of four years. One quick little tool that’s in everybody’s toolbox.

Cassie Gillespie  (10:15):

Yeah. That’s super helpful. Do you have data on how reliable it is?

Tracey Wagner (10:22):

Very reliable and very sensitive. So it’s accurate at almost 80 to 90% of the time.

Dr. James Metz (10:32):

Right. I just reiterate that it is very accurate. It’s very sensitive, meaning that it picks up a lot of bruises. The specificity is a little bit lower but that’s why we use other information to kind of come up with a determination of our level of concern for abuse. So we don’t just look at the bruise, but it is one tool to help us screen for abusive injuries.

Cassie Gillespie  (11:07):

So when we’re talking about these types of concepts I think it’s always helpful to ground it in, in real life examples. Can you walk us through any type of case? Certainly not with identifying information, but just to give us a idea of how TEN-4 might be used in the clinic or in the child safe program.

Dr. James Metz (11:25):

Sure. I can start. I’m sure Tracy has plenty of examples as well, but we see children in the emergency department all the time and it’s a high paced high volume area in the hospital. And so we need to be very careful about picking up sentinal injuries, such as bruises. So a child, maybe four months of age comes into the emergency department for a cough. And the emergency department physician notices a small bruise on the back of the child. And the physician asks the parents what happened? The parents don’t have a good explanation, and there’s a decision that the physician can make the physician can say, well, that’s, you know, it just looks like a normal bruise or the physician can remember the TEN-4 rule or those who don’t cruise rarely bruise and decide to do a further workup. In my experience, and we’ve had several cases like this when the physician decides to do a further workup, which includes doing some X-rays, doing some possible blood work, we have found further injuries. So a rib fracture or a skull fracture, or a clavicle fracture in a child. And those would be injuries that you wouldn’t see necessarily from just looking at the child, but would be an indicator of further injuries that would have to have further explanation for. So this is real life. We see this in the emergency department children coming in with all different types of complaints, and we need to not only address that complaint, but also look for these subtle injuries called sentinal injuries that may be missed if we don’t stop and consider them as abusive injuries.

Cassie Gillespie  (13:23):

And this may be, you know, already evident, but I just want to make sure it’s super clear. So the presence of a bruise certainly is not a certainty, but could be indicative of an injury that you can see and in the cause of that injury or as that injury happened is how the bruise developed. Is that how they’re linked? I guess my question is how does the bruise connect to the unseen injury? Does it always, or are they just correlated?

Dr. James Metz (13:52):

Yeah, it’s a great question. So sometimes they are correlated. Sometimes you see bruising over a fracture. Sometimes the bruising can be isolated and an injury in and of itself. But you know, as a small bruise on the chest of a child could be from a parent or a caregiver gripping a child and that’s all you see. And when you do the X-ray, you see some rib fractures, or you might see a bruise on the cheek of a two week old and we know two week old shouldn’t have bruising on them. Unless we know that maybe they fell out of a grocery cart for some unfortunate reason. And then we do a head imaging and we see a skull fracture. So these are small bruises, that overlay injuries that you can’t see without doing further investigation.

Tracey Wagner (14:48):

I think that often as kids are really resilient. They’re made to take a lot of rough and tumble. And even in my history as the nurse on the floor, on the inpatient pediatric floor, you could see a child that had been in a pretty severe car accident and wouldn’t have any kind of external injuries. But then when you go to look inside the body, there’s lots of surprises and things to be worried about. I also think about preschoolers or the older age group kids who have bruises to their ears. And that that’s a common thing that we get asked about often is this bruise worrisome. And when you think about the world in general, you don’t see a lot of kids running around with bruises on their ears from play. And so that’s something that, that is always worrisome and from a form of discipline used as discipline. It’s something that we want to look into further and, and can cause internal damage, that outside injury is a marker of perhaps some internal injury.

Cassie Gillespie  (16:01):

Gotcha. So I’m starting to develop an internal list of injuries that might be more concerning or a bigger red flag than others. And I want to stop and check my own assumptions. So I’m hearing that any bruises on anyone under four months old, especially newborns really concerning with the older set, those ear bruises can be concerning. Are there other types of bruises that are really concerning that you want to make sure people pay attention to?

Dr. James Metz (16:29):

Right. So again if you go by the ten four rule, so the torso ears and neck, any bruise in that location in a child four months of age to four years of age is very concerning. We also look at any sort of patterned bruise, so a bruise that has a pattern to it. That’s pretty uncommon unless there’s a good story for it. So something with a right angle. Sometimes is indicative of a belt mark. Sometimes we see handprints on the body and that’s concerning obviously for a slap mark. So we also look for any sort of patterned injuries, any injuries to the genitals in kids is very concerning, it’s not common. And so we need to take note of that as well.

Cassie Gillespie  (17:22):

That makes sense. I have a question that I think I know the answer to, but I want to just double check here. Can you date injuries by the color of the bruises? Can the bruises give you information about when the incident occurred?

Dr. James Metz (17:35):

I think Tracy should answer this because I harp on this all the time.

Tracey Wagner (17:40):

So the answer is no. No there’s no science around the color of a bruise to indicate the age of it. We all see colors and interpret them in very different ways. So I might see purple and you might see and also children’s bodies are all very, very different and display colors and shapes and sizes that are, that are different. So bottom line is no, we cannot age bruises. We all have sort of an idea that they kind of transitioned from color from purple down to yellowish brown. But again, there’s no way to scientifically positively identify dates and ages times of bruises. When you do find a bruise, if you’re working and you see a bruise that you think might be a sentinel injury that you’re concerned about, what should the next steps?

Dr. James Metz (18:40):

That’s a great question. It depends on where you’re located in some ways, meaning if you’re in the clinic, if you’re at a school setting, if you’re in the hospital. But the first thing to do is stop and take note and not just pass it by. Again, bruises and children, as you mentioned, Cassie early on are pretty common. And again, they’re not always concerning, but sometimes they are. And recognizing that alone is a huge step. I teach all pediatric residents and trainees to put it on their differential diagnosis, meaning put it as something that is a concern and think about all the things that it could be from bruises can be from bleeding disorders. They can be from viruses. They can be from normal play, they can be from child abuse. And so you have to think about it. And so I think just the awareness that some bruises are worse than other others is really important.

Dr. James Metz (19:42):

The next step is then to do an evaluation. And again, depending on where you are that evaluation may need to be done at a different location. So if it’s in the clinic we recommend that the child be seen fairly promptly by a medical professional to evaluate whether that bruise truly is concerning or not. If it’s deemed by a medical professional to be concerning, then it needs further investigation. And what that investigation looks like is depending on the age of the child, it can be further imaging. So imaging such as a skeletal survey, which looks at all the bones in the body and for the very young children under four months of age we get head imaging to make sure there’s nothing concerning for head injury. So depending on the level of concern and the age of the child, we have a fairly standardized workup that’s based on data and research and, and standardized across the country of how we work up bruises for possible abuse.

Cassie Gillespie  (20:51):

Thanks. And one of the things that I’ve been thinking about a lot lately, and I know lots of folks are thinking about a lot lately with all the things that are going on in the news is how our systems may inadvertently or consciously play into racism versus anti-racism and power and bias. When we’re talking about standardized workups, those are always places I get a little curious. Can you talk about how the Child Safe Program, or even just the kind of protocols in general account for bias and all of the subtleties that different identities people might have?

Tracey Wagner (21:31):

I would say that we are trying to always hold ourselves accountable to being objective and careful and strength based and family centered. So engaging with families working with our community partners, all those mechanisms really help us to be accountable. And we have to ask those tough questions of ourselves. Is this the right decision? Are are we being objective and clear and, and thoughtful about the process. So something that we try to hold ourselves accountable every time, every decision that we make. So, and then with the standards in process that ensures that we’re doing an objective medical work based on medical science and evidence and research, and that our workups are objective and evidence based.

Dr. James Metz (22:30):

You bring up a great point and I appreciate you bringing it up because it’s especially relevant now. There is good science and good literature that shows that underrepresented minorities are treated differently in the medical system and that’s across the medical system and not just with child protection. And so it’s unfortunate, but we know from a child protection standpoint that underrepresented minorities are often treated differently when it comes to a workup for child abuse and the ways that we can combat that. And we are trying to here in our hospital, because everybody has a level of implicit bias and that they come to work with is to develop protocols that are standardized, that it doesn’t matter where you’re from, what socioeconomic status you are, what race or religion, gender that you get worked up because of the injury and not because of any other social factor.

Dr. James Metz (23:37):

And I think that’s really an important point to drill in on, because I would hate for people to fear coming to the emergency department, thinking that they’re going to get treated one way because of the way that they appear. And that would be very disappointing. So we are working very hard to standardize the process to the degree that we can so that when a child comes in for a child abuse evaluation, that they get the same care, regardless of all these other factors that come into play.

Cassie Gillespie  (24:12):

Thanks for explaining that that’s helpful. So we’ve talked a bit about bruises or a good bit about bruises. Are there other injuries that are sentinel injuries that you just want to name up and make sure people are aware of and paying attention to, or are we really just focusing in on TEN-4 and those bruises that are kind of unexplained or in a vulnerable area?

Dr. James Metz (24:31):

There are other sentinel injuries. Bruises are obviously the most common, but we also think about the tear of the frenulum, we think about bleeding in the eyes of children, of the whites of the eyes. So that’s not very common in young children and is indicative of some sort of trauma that we need to be more curious about. Some people would consider subtle fractures as such a sentinel injuries. Other people only think of them as outward injuries that you can see visibly. But those are the types of injuries that we get concerned about.

Cassie Gillespie  (25:08):

And just in case, there’s now a rush on the clinic with people who have thought about some bruises, are there any bruises that people don’t need to be worried about? What are the normative places where people shouldn’t get too worked up?

Tracey Wagner (25:24):

The bruises that we don’t worry so much about are bruises on shins. I’ll say my oldest son is now 39 and I am the mom who took him to the pediatrician because I was worried about bruises all over his body, but they were just normal, healthy bruises. Bruises on bony prominences because that’s where, where contact happens and there’s not much fat protection to help, bruises on foreheads.

Cassie Gillespie  (25:59):

What’s a bony prominence?

Tracey Wagner (26:01):

Oh, sorry. Yeah. So bony prominence would be like your knee or maybe elbow, or your shoulder blade, anywhere where a bone is kind of sticking out and hip bone sometimes where there’s not a lot of fat covering a forehead. Bruises are often not so worrisome and common because of kids and gravity. They just sort of fall down and hit the ground first, right. Bruises on scalps. Because again, there’s not much fat covering there and they look worse than they are. It doesn’t take much pressure to cause something that looks pretty bad and that’s a very common area to get bonked. And then upper legs are also kind of common area. They’re a big area and you can fall on, on a toy and that might be your leg that hits it first. So those, those are some common places.

Cassie Gillespie  (26:55):

Thanks. I think we’re going to wrap up. Is there anything else you want to make sure folks know about this topic before we close up?

Tracey Wagner (27:03):

I wanted to put a plugin maybe for the Child Protector App. It’s an app that you can download on your phone and it’s medically based. It’s out of the University of Texas, it’s Dr. Nancy Kellogg and she’s a world renowned expert on these issues and Children’s Mercy Hospital. But it’s really kind of cool. You can actually just type in exactly what you have in front of you. So if you type in bruise on a two month old on their forehead, and it asks you some questions, like, is there a story or are there some medical concerns and it points you in the right direction. So it gives you some questions to ask and to be sure that you’ve investigated the situation further. It’s pretty easy to use. It also encompasses some things like fractures and burns, it’s good to just check out it’s a good teaching tool. It’s also got some embedded videos that sort of explain how you can not actually see bruises or injuries on the outside, but injuries have occurred on the inside. It’s cool. I use it a lot.

Cassie Gillespie  (28:13):

Awesome. James, any last thoughts from you?

Dr. James Metz (28:17):

I just appreciate you spending some time on this topic. And I would just leave everybody again with the two reminders that those who don’t cruise, rarely bruise and the TEN-4 rule.

Cassie Gillespie  (28:27):

It’s super helpful to have them just be things you can remember like that. And for our listeners out there, we did a sneaky thing here and we got James and Tracy and for two episodes. So we’re going to record another episode with them on medical child abuse, and that’ll come out in a couple of weeks. So stay tuned for that one. And James and Tracy, thank you so much for joining us today. It was really great to have you here and chat with you a little bit.

Dr. James Metz (28:51):

Thank you.

Tracey Wagner (28:52):

Thanks Cassie.

Cassie Gillespie  (28:53):

Thanks for listening. If you have any ideas about topics that you want us to cover or episodes that you’re interested in hearing, shoot us a message. You can reach me by email at, or you can leave us a comment on the web page where you downloaded this podcast. Welcome to the Field is produced by the Vermont Child Welfare Training Partnership and the State of Vermont, and a special thank you to Brickdrop for composing and recording our music. See you next time!

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