 Get this up and then share it So are you looking at a document? Yes. Yeah, good very good. All right. Well seven o'clock. Let's start For those of you that I don't know Bob Hoffman, I am the old guy in pediatric ophthalmology source of most blame and Purpose of this talk is basically to for the new folks Acquaint you with what is Across the bridge, you know at primary and not Necessarily as much, you know about what's going to happen when you rotate with us because that will become readily apparent And you'll get additional documents about that But as you take call as you're asked to do consults You need to know where things are one of the things that I asked a Lane to get out as far as a kind of a homework assignment before this was to make sure all of you had had a tour of primary To include the highlights that you need to know about in terms of functioning, which would include our clinic The er icu's nicu patient wards Places where you can get free food Mainly places where you can get free food And how to get in and out You do all need, you know badges if you don't have badges, you're going to be in big trouble In terms of getting into things. I mean if you're really stuck you can always call security at primary Useful to know the the number to reach the operator and get security if you're just grabbing a phone somewhere is 801 662 1000 from outside And they can find security. They can meet you somewhere in as long as you have some ID and a badge and a reasonable story. They'll let you in We have three different locations only One of which you're responsible to cover as far as on-call and consults When you are on the service with us, you may be sent to riverton or farmington for clinic And that again, you'll learn about at the time in terms of getting directions to get there But you definitely do not need to go to any other hospitals Other than university hospital and primary to see children infants or neonates You know right now there are five members of our division myself Dave Dries Mariela Young Mimi Leah Owen and Griffin Jardine We also have a wonderful orthoptist Julie Harmon. And when you come over to spend time with us She will be a major asset in terms of giving you Insight into ocular motility You'll learn to do RLP exams hands-on at both of you in primary Who's on consults now? That's Sean Collin Okay, not on the not on the on the Uh a session yet No, he's on the session. Okay. Any issues as far as call at this point Sean? I guess not So, you know again as far as getting into primary, you know with covet issues Basically wash your hands when you come across the bridge let yourself in Because nobody's guarding the gate on the fourth floor anymore So it's no longer an issue of being interrogated You know having your family history checked and your temperature and whatnot If you do get calls, you know when you're on consults from outside Feel free to talk to the resident honor service to one of the pediatric ophthalmologists Or if it's after hours to your attending on call attending To see, you know, what what to do with that We basically take pretty much anybody anybody wants to send to us But we probably should talk about it before we accept the transfer um As far as one other thing to make you aware of and Um, I know Catherine you've not been down to american fork yet. I I think that Uh, um, is that right? No, I haven't been I haven't next I'm going next monday next monday. Okay. Very good You know, the american fork training school for those of you who don't know is basically a place where severely Developmentally impaired children were once Housed and as a residential school And a facility for them, uh, hence the name school And the idea was to try to train them to go out and do something in society And it kind of evolved into a place where unplaceable adults with severe developmental Disabilities reside And we do provide their eye care. That means you provide it you do get Some reimbursement for it in the form of credit the bookstore That I arranged to have that passed on to you because I was Had my arm twisted into taking that over When the you the word school was used implying children Unfortunately, there are no children there But if you do have issues there, let me know and otherwise. I think it's a good opportunity To work a bit independently any surgery that comes out of there that you're capable of doing you should do Arrange in attending And and go for it and I think you'll find the staff out there is very helpful Oh as far as Service coverage kind of going through this document and again, this should have gotten to you To review ahead of time and if anybody has questions concerns or anyone who's been there has comments Jump in um As far as consults during the day now, we do have a first year resident pgy2 Responsible for consults And I'm very grateful that you're doing those realize that I think it's certainly early on Important to run almost all if not all of those consults by an attending Often convenient to do that run it by the attending who is in clinic and just stop in We'll talk in between patients and we can figure out whatever You know issues have arisen in the er Again during the day it's going to be the consult resident after hours the on-call resident We have All sorts of instruments that you are welcome to use in our clinic But please realize that they come back to clinics so they're there when you want them next Please take care of that portable slit lamp When it drops on the floor it does not bounce well And that has happened and takes a while to get the darn thing fixed If you've not been through our clinic to know where the instruments live that you can borrow Grab a more senior resident and and and do that It's useful to know where to get things and also where to put them so they're clean and ready to go the next time If there are Issues that come up either consult wise because one of our post ops has become an inpatient Or after hours feel free to call the attending involved call the resident on the service And realize you may wind up in some political issues with people Trying you know because there is at times some overlap in some of our services particularly with ocular plastics In terms of who's fixing orbital fractures and things of that sort even eyelid lacerations But I think that we need to be committed to doing what's best for patients Which basically amounts to saying that you know if We need to look at the patient's eyes and ent is going to fix the floor fractures And we can all work together and give the patient taken care of Why not? And you may find that ent may invite you to go to the or with them to see how they fix You know fractures or do what they're doing and Feel free to do that The issue of Abusive head trauma non-external trauma You will get called And for most of you this is a review but When you see those patients you want to make sure first that it is okay to dilate through pupils Often these kids have significant intracranial injuries And the gatekeeper for that dilation is going to be the neurosurgery service So when someone calls you it's always good to ask. Can I dilate the patient? Please check with neurosurgery You know if they're on their service Because you may have a general pediatrics, you know Intern calling you or the intern that has been assigned in the PICU And we want to make sure neurosurgery is okay with us dilating the patient If they're using those pupils to follow the patient's neurologic status Once you've done that any patient who has retinal hemorrhages Needs to be seen by somebody more senior than you kind of as a mantra Mainly because we need to be able to provide a little bit input as to what it means Secondly, if something goes to court I want that burden of having to sort this out and go to court to fall on me or one of my peds colleagues Not on you if we haven't seen the patient it probably will fall on you Now we'd like to get photographs and OCT when possible on almost all of these kids if They've got hemorrhages and It can wait until tomorrow It's weekday Because if these things often get asked, you know for a looksie at night We have things set up through photography Mel has now moved on but glenn is probably ground central and mel can still help with this mel's currently our rlp coordinator She's no longer a photographer in photography But they will come to bedside with you and take photographs And if there are circumventative folds Do OCT and if you are not yet clear on what a circumventative fold is we're going to look at them in just a bit Find someone more senior and get a look with But you're welcome to call me at any point about these nat kids I've always got my cell phone and i'm happy to talk to you and let helpful advice about what direction we should go in And so my pager Homephone cell i mean the pager just goes to my cell phone now the pager doesn't physically exist anymore But you're welcome to call me Now as far as rotations i mentioned consult rotation first year Second year you spend three months with the four residents three three months On our service full-time and you're welcome to come back If you're interested for an elective in the third year If you didn't get enough of us or you just want to do something different And we're happy to work out individual experiences either here or possibly on an international elective As far as the clinic experience you'll Learn history and exam skills Make a note in epic And I want you to commit yourself to what you think in epic I think that's a useful exercise But you're going to develop skills in vision assessment and kids motility measurements Refraction and and I you know, I expect you to be able to do good retinoscopy when you get done And to do enter segment fundus exams even in neonates, you know at bedside Use that information to come up with a differential diagnosis and a plan and then Also good to gain some understanding in the interaction between our services other services at moran like pediatric retina glaucoma And be able to Interact with those folks also other pediatric specialties and support services like the parent infam program and early intervention Now as far as surgical experience again, if you have the opportunity to come to the or with us ahead of time Have some loops if you don't have loops I do have one set That you can use it's in a headset thing and it's there for that purpose and Use that to do practice surgery if you want to borrow it. Just let me know and I'll make those arrangements And then as far as reading materials there are A number of texts in the library. There also are texts on the bookshelf in my office at moran and During normal times laura power my assistant can let you into my office Darcy who sits next to her into that actually here and not at home because it's hard for war to unlock it remotely Can let you in she has a key and you're welcome to sit there to your heart's content Yes, it's a mess, but there are a lot of books and make yourself at home and and read Um As far as my recommendations about what you do, you know, just in general not necessarily just for peas But as a resident An hour a day of reading on general ophthalmology issues an hour a day and whatever subspecialy you're in And then read about at least one or two interesting patients that you've seen every single day And any day you don't do that you're behind um Now as far as you know Your id if any of you have trouble getting an id or getting access let me know I would get ahold of medical records at primary if you have not already and get a dictation number And that way when you operate with someone That dictation will get back to you'll have your number And if you dictate it'll get back to you And make sure you have access to icentra as well as epic and again if you don't Give me a call give kathryn a call. She's on the service now and she can help arrange that um Now for those of you who've spent time on peas and spent a lot of time doing consults and things seeing things What insights do you have to share with your junior colleagues? um, I would say with pediatric examinations Just be very patient And then I think the hardest part in your guys's shoes is just getting used to examining kids Other comments concerns for the new people. Have you had any issues that have come up at primary that I can be of help with at this point? I've actually been uh Maybe I've just been fortunate, but I've been kind of pleasantly surprised by um How easy some a lot of the kids have been to examine If if you just do kind of what kathryn was saying Um, especially done ed Um, and I haven't run into any problems. Everyone's been really helpful kathryn has offered to Uh come see patients with me when she's in clinic and that's been super helpful as well So I've been trying to take advantage of that Yeah, you know a couple of things shan good's kind of segue and I'm glad you made those comments um It sometimes, you know comes up that you really you know for me the issue at times is What is it? I need to see in a kit and can I see it with them away? Can I hold them still and get it done or you know? Do they need a bit of sedation and and often in the er the child's frightened? They've been there for hours. They're starving They're angry and they don't want anything to do with you and so it very appropriately may be the case that you need to sedate them to get a good look to make sure that They don't have some intraocular injury when they've had a penetrating eyelid injury or something of that sort And when the situation comes up that you're going to sedate the child particularly for the very junior residents My strong recommendation is when you make that decision that gee, I think I need to sedate this kid I would do two things I would run that decision by somebody more senior more senior resident probably To make sure that they don't think they could get a look at which point then you've saved the patient of sedation And then the other thing is that if there is anyone you think needs to be there When the child is sedated so they don't want it being sedated twice Call them get them there coordinated Probably results in better patient care and it may result in a better learning opportunity for you The other Corridory with that is that you may well be called either on consults or on call By one of the nikkus And if it's a question about gee so and so didn't get an exam yesterday When they were there doing r.o.p exams. We're sending them home tomorrow We want you to come right now tonight to do an r.o.p exam I'm not entirely comfortable with putting that responsibility on you guys I think that that is a decision That needs to be made in an attending level Maybe a fellow level, but definitely not. I don't think a resident level Because there are huge medical legal implications if we Say one thing about r.o.p. And the patient has a bad outcome and they went home with our blessing And I rather that that decision it may be that it happens anyway Sits on one of our shoulders And not your shoulders so that I think the thing I would urge you to do if you get that call He has passed that on to one of the pediatric Ophthalmologists and again, you're welcome to call me During the day you can certainly call kathryn and she'll help you sort out what to do But realize I do not expect you to do after hours r.o.p exams Or take again take the whole hit and the responsibility in terms of the abusive head trauma kids We need to be involved in that it's kind of our job to provide backup and teaching with that um What other issues have come up at primary? that One thing I want to make you all aware of now who here on the call has been called to the er at primary To close a lid laceration that you have gone ahead and closed yourself in the er Yes, I have Okay, the one thing I want to make you aware of is and I don't know that you all are aware of it But there was an issue about six weeks ago, maybe a little longer Where our kit that was put together to You know for lid lacerations in the er so you'd have everything you needed to take over there was used Unfortunately, there were latex containing gloves in it And a nurse in the er was exposed to those latex containing gloves and had a very serious reaction to latex um and so Um, I'm catherine. I'm going to be asking you to talk to your colleagues here at some point We need to come up with some instruments that we want to have and maybe just the instruments out of the set If you're happy with that But we're going to want to leave everything else but the instruments out of the set And then I need a list of all of that from someone because I need to go to the er And present after them so they can put that together Their end of the deal is if we're going to change that situation My expectation is they'll have every last thing that you need Together so that they can have that there so it's still seamless for you But we're using their supplies and we just have our instruments We could also ask them to get some instruments probably time at least to rethink this and Catherine if you wouldn't mind taking the the lead on that And then sorting through that. I know that the latex gloves were pulled out of our sets our our Kit to do that But we we need to kind of look at the rest of that stuff as well Yeah, sure. Absolutely. I mean I think that Go ahead. Yeah, I think chris bear Had emailed all of us to make sure that we don't use latex clothes anymore But yeah, I can I can we can look at the List of instruments in there. We have a list actually already so I can send that to you You have to get the list to me, you know, I am absolutely in complete agreement That it's great to have our own set of stuff to take over there I think that the er is feeling a little bit uncomfortable after that In terms of the supplies they want to know that the supplies are sterile and all that stuff and um, I I don't have a A huge issue with that as long as it isn't a matter of you having to wait Endlessly for someone to round up supplies. I expect them to be already collected. You know in a Kit or something for you to be able to use so that you don't have to wait So that this is also probably a time to just to rethink that kit to see if you all want to change anything now I want to as far as um I think that's it in terms of this topic, but I've got one other and I need to see now if I pull this up if I can close This unless we have more questions about that And then I want to bring this up and are you seeing A powerpoint presentation now Yes, yes Good Willis and I think if I did that right this should work This is brief and I'm sandbagging with this because this wasn't on the homework list But the book that I mentioned that non-external trauma book is in our clinic It's in the library and it's on my bookshelf There are two chapters in there that are definitely worth taking a look at Mainly for the photos in it because the photos are good. I must say I did take most of them um but That book was written mainly for attorneys to use when they're trying to Either prosecute or defend Perpetrators or prosecute them and so that was the orientation of it and I wrote the i stuff in it And it's not entirely dated. There isn't good oct information in there because people were not using oct we'll talk about that but Abusive head trauma Is one of my clinical interests and I've been involved in it by default because people keep shaking their children And they keep coming from this part of the country to primary You know vitreous hemorrhages and intracranial bleeding were described by terstenbeck in 1900 and kaffe Who's a pediatrician in the 1940s described this combination of subdural hematoma and fractures That were an indication in his mind of child abuse in the 70s the term shaken baby syndrome was coined And then recently that has fallen by the wayside the term abusive head trauma has Been used and this affects a lot of kids And your findings and evaluation when you see these kids Are are important and they may well be used both in patient care and in medical, you know legal proceedings And somewhere up to you know 80 percent of kids that have known Shaking have hemorrhages and the hemorrhages have consequences realize your Your examination and everything you write down or put in epic or eicentra May wind up being something you get to discuss with attorneys in front of a court reporter or in front of a judge And I would approach it that way And we have an obligation to communicate those findings to those that need to know which would include the care team at the hospital family and law enforcement and then This part of it often gets left out of these discussions and that is these kids have ongoing problems We'll touch on briefly With changes in retina changes in brain vision pathways that may require support may never get better When you see retinal hemorrhages There's nothing that makes a given child There's nothing that just says this is child abuse But there's certain circumstances where it's a lot more suggestive than others and if you've got hemorrhages that are in multiple layers they are Throughout the retina that is highly suggestive and there are In there are peri micro folds these little folds outer area away from the fove around the edge of the macula And retina schesis splitting the retinal layers big bolus changes in the the Macular area those are an indication that there's been likely some acceleration deceleration injury with substances that are different moving against each other The current thinking about peri macular folds is that the vitreous is tacked down in that area and over retinal blood vessels And that has to do with why you develop both the folds and the schesis changes Now if we were to look at this patient um I need a volunteer describe what you see in this picture Which eye is it? What are we looking at? volunteer So it's a funnest photos of the right eye Yep showing Retinal hemorrhages and all four caudgents and all three layers of the retina Including in the fovea Don't see evidence of peri macular folds Or schesis, but maybe hard to see the optic nerve is largely obscured It is although when you look I looked at that and if you magnify I'm not convinced that optic nerve is swollen There's retinal edema, you know that makes it hard when It's temporal to the optic nerve. There's a lot of swelling in the retina but when you look at this And then if you carefully You know depress the patient and you look out you would see hemorrhages all the way out to the oris serata You know, so this is the kind of patient where this is highly suggestive of abusive head trauma And I carefully choose the wording I put in these darn consults You know where it could be compatible with to highly suggestive You can't say it's diagnostic of because there are no changes that are like that But where you've got multi-layered hemorrhages that extend throughout the retina That is a different kettle of fish than the patient who comes in that has You know superficial hemorrhages mainly around the optic nerve and in the posterior pole Now what would that be more compatible with? If you had just superficial hemorrhages So not multi-layered just around the optic nerve What would you think in a child the most likely scenario would be? How about increased intracranial pressure? And that's probably the most common culprit So this would be the child who's got sudden shunt dysfunction. Their pressure goes way up Those kids will wind up with a few hemorrhages around the optic nerve the child who has blunt head trauma Has You know an intracranial bleed a subdural is limited That an increased intracranial pressure that child, you know, you may see they've got bilateral six nerve policies from the increased pressure But and and so that child I would still say it could be compatible with abusive head trauma But You know, you have to be less strong about it. And I think we have an obligation to maintain equipoise Recording these changes That's good. Good description marshal. That was very good. And Let's see what else now this patient. What do we see? You know, if you looked at let's go back to that previous one if I were to ask Am I worried about the patient's Vision at this point is what's going on here interfering with the patient's vision? Is it, you know, absolutely possibly or not at all? Uh, almost certainly since there's stuff scaring the phobia looks like pre-retinal Absolutely. Now, I think that that's the case and here you'll see even more in this left eye What do you see? You know in the in the posterior pole there You much much larger hemorrhage, isn't it? in that left eye You know in the macular area and more confluent pre-retinal hemorrhage there Um, and that definitely will block vision my point here being that not only do we need to think about what's going on and what the implications of it But I kind of go through a little bit of a checklist in my own mind when I see these kids and say How worried am I about this child's vision? I mean if these hemorrhages don't clear I may need Emmy to go in and you know and do something because often hemorrhages like this one Here in the this hemorrhage this if this is pre-retinal if it breaks through Into the vitreous you wind up with a large vitreous hemorrhage in front of the phobia That can interfere with you know vision development in an infant or a toddler So that's something to keep in mind now Another patient again. This is actually this is same patient different view And now what are we seeing here? What is this thing? You know like the positive arrow sign What is this? That is a circum-macular fold This is the optic nerve phobia is down here the picture is a bit rotated Mainly because the photographer that would be me didn't have the camera oriented appropriately Um, but this shows that fold Um, and it's very striking when you see it and it again is something that Really raises um suspicion of acceleration deceleration forces with the head Which is the currently? Um presumed mechanism Um, and you all need to realize that most of what we know about abusive head trauma comes from perpetrators Professing and putting that together with those exams And then looking at series of accidental head trauma There are not wonderful studies looking at the mechanisms of this now britney coats who is um You know professor down in um engineer the engineering department. She's a mechanical engineer She Has done is doing elegant studies to look at this but you know, we still don't have A good explanation that fits with what we think is going on clinically So our thinking about this in your practice careers may be changed by you know, folks like dr. Coates and her modeling Um, and she's trying to work this out, but it's it turns out that modeling what is actually going on In the eye is Proving to be quite difficult Another fold in this right eye close up Now what about the sequelae and and this is where you know Make sure these kids get in for follow-up and you know what I Talked to the parents about Issues and these kids I like to surprise them a bit with the idea that you know may mean that your child was shaken and and observe Their reaction to it And I have had the experience on multiple occasions where after I've had that discussion They the perpetrator decides to fess up to whoever Is seeing them from safe and healthy families But that's not the the major purpose of my telling is just to describe what the findings are and to let them know that Follow-up is essential. I ask them where they live and see if we need to you know to get them to see somebody In montana or nevada or wherever they've come from if it isn't local But central vision loss due to changes in brain tissues Optic atrophy either associated with increased intracranial pressure or just due to Direct injury to tissues is very common And subrentinal neobascular membrane formation is not as well recognized but does happen Now What do you see in this picture with the positive arrow sign? Somebody tell me what they see here Is that a normal nerve No, I'm not quite sure what the arrow sign is indicating But the the nerve looks very pallorous and it has also like a almost like a ring or Like atrophy around it Yeah, the the atrophy that ring may have been there and may be normal But that nerve is clearly pale you know axons Have left and and and the purpose in showing this is that you may see kids in clinic In the history may not be clear. They may have been hospitalized for a head injury And the retinal hemorrhages Can disappear quickly There are some studies now that suggest that a lot of hemorrhages may disappear in some of these kids even in 24 hours So the point being that you may be left with a situation where you don't have hemorrhages to look at You've got a pale nerve You're trying to put things together and decide what happened and this is not an infrequent sequelae now There are erg changes. You'll see Changes like retinoschesis with laws of the b wave on erg That may help you sort things out OCT may show thinning Of the nerve fiber layer around the nerve Um, and you may wind up with changes like this. Now somebody tell me what they see in this picture What do you describe what you see? Don't leave it all on Catherine. She's picking up the weight here I'll give it a go So photo of the right eye um Central area particularly around the macula appears well appears that the um vessels are elevated Um, there's also kind of a gray coloring to it. I don't know if it's indicative of edema or Right. No, that's a that's a good description and could be edema Could be a mass To give you some background. I met this young fellow when he was six months old He was sedated intubated in the pick you at primary in the old children's hospital And he had confluent retinal edema multi-layered retinal hemorrhages from optic nerve to aura serata and had a significant intracranial, you know hemorrhages and They had called me to come see him because they did not think he was going to survive And so I got one of those phone calls saying We need you to come to the pick you now because this child may not make it and we want To have your exam and we want photographs taken And so these photographs were taken later with a Zeiss fundus camera But the photographs I initially took at bedside were with a handheld kawa film camera through a 20 director lens Documenting those hemorrhages and I followed this child and this picture was taken when he was a teenager And he has huge bilateral sub retinal nevascular membranes And mike teski and I went back and forth About options, you know, there's no way to laser any of this without destroying his central vision His best vision has been stable at about 2200 And I followed this kid till he was grown. I was invited both to his high school graduation and to his wedding and You know followed he and his family and The perpetrator was never sorted out in that circumstance Nobody ever fessed up and they were not able to make an arrest but clear in my mind that this child had been shaken by someone Probably someone very close to him, but sub retinal nevascular membranes Are, you know, occasionally occur and and these have remained stable and he's followed, you know, by a retina doc now yearly This is the other eye with similar changes and so Mike doc teski recommended that we simply follow him regularly. He didn't think that doing anything surgically was going to help Um, and lastly with this, you know, our ocular findings alone pathomonic of abusive head trauma and The answer to that in my mind is absolutely not and the way, you know, what I tell people when they say well, you know Is it pathomonic? No on the other hand if you've got confluent hemorrhages multi-layered that extend from optic nerve to aurocerata and you don't have a history of Either a fall like this time of year through an open window onto concrete, you know From a at least two stories or the child was an unrestrained missile in a 60 mile an hour head-on car crash Then it's highly suggestive that they were shaken and somebody needs to sort that out You know one of the questions that should be in your mind is well, are there accidental head injuries That have been reported with findings that look just like what we think are very very suggestive Yeah, the reason we put that caveat in there. There's a case that every attorney that defends You know accused perpetrators knows and it's a child of a toddler Who climbed up onto a tv console and pulled a huge tv set Back on top of him crushing his head Killing him and causing changes that at autopsy looked just like what we describe In abusive head trauma so that if you pull a very large television set over and you crush your head You can duplicate these findings, but it requires Horrific head trauma and there are kids again with massive accidental head trauma that have had changes that are suggestive And you're all aware I think at this point and should read about all of the various things And they're listed in that those two chapters Reference about all the different things in the different differential diagnosis like, you know Glutaric acid urea type two and various things that we don't think of a lot in ophthalmology That get looked at in in the work up There's some other things like Gee, I had bad retinopathy prematurity and somebody bumped my head and I had a You know retinal hemorrhage those things do happen and it's our job to sort those out um I kind of see our role as trying to be a good advocate for the Patient and at times the family in terms of sorting this stuff out Now how many of you have seen kids with changes that we have Described as being highly suggestive of abusive head trauma at this point in your careers I have Yeah, other people in my class have Everybody in your your class have for the the now the first year residents. Have you Had that experience? When I was on buddy call, yes Okay, and you want to not okay, you know and and it'll happen and um It'll bother you You know, I still remember the very first child I saw With abusive head trauma mainly because I did stick my neck out and say I thought it was child abuse And the kid's dad came through the university of michigan Mott children's hospital ICU came through the front door with a gun looking for me And security and the nurses booted me out the back And the guy had basically killed his child Because I was seeing the child for the first time just prior to his becoming a multiple organ donor And dad had shaken him and had crushed crushed a couple of vertebrae Pushing the child and grinding him against a chair And it was pathetic But I still remember that kid mainly because my son was the same age So that all you know hits close to home and if it affects you and you're really bothered by it I mean feel free to call me and we'll talk about it because it is real and You know At least one person that you know, well, I won't mention by name But when she was a resident in our program, I mean had one that was again the same age as one of her kids And it hits close to home Um Concerns or issues or things with our approach in terms of this abusive head trauma Issue that we need to talk about because this would be a good time to to go through them if there are Um, I think the only thing dr. Hoffman is that uh, we've been told by chiefs of previous years and kind of like That our policy is that we don't See these kiddos specifically for looking for retinal hemorrhages One, uh, of course, if they're not cleared for a dilated exam yet or two If safe and healthy families has not specifically requested these exams I'm also like you said for a liability and safety reasons from our end I think you're right I think that and that is as a great point Catherine to bring up the issue that she's bringing up Just to clarify it is the issue of being asked to take a look Undilated at the kids and then render a definitive opinion about whether there are a retinal hemorrhages and b Are they suggest of abusive head trauma? And while I think it it's very likely that you can get a look and say there are hemorrhages present Or I don't see hemorrhages It doesn't mean that there aren't hemorrhages to be found. You just can't see them undilated and Things may look quite different when you actually get to look dilated And we don't want To set all those wheels in motion based on an inadequate exam So I think I agree with you a hundred percent I think that from my perspective that still holds that we don't Want to examine those kids until we can dilate them unless there is some very compelling reason to do so And when that is the case, I think you have to state If you're looking on dilated that this is an undilated exam It really isn't adequate But it's being done under extenuating circumstances and limit The you know the the findings to I saw retinal hemorrhages. There are retinal hemorrhages present Or I didn't see retinal hemorrhages and with the hemorrhages, you know, I I when I'm asked to do that I just make a note to say that I can't say The extent, you know, I can't really determine the extent of them until we can do a dilated exam for background on that the reason that this Was brought up as an issue of seeing them urgently Even if neurosurgery doesn't want them dilated Is that there are reports in the child abuse literature of hemorrhages changing fairly dramatically in the first 24 to 48 hours, you know after injury they can start to resolve and And so I think that If we can convince neurosurgery to do that and at our institution You know that has we've had one very conservative neurosurgeon. He also turns out to be the guy in charge Who has been reluctant to let us dilate pupils As early as either safe and healthy families or ophthalmology, obviously would like to And being that they're the ones that are taking care of the kids brains and if the kid does start to herniate They're going to have to deal with it. I have to still defer to their Uh decision-making, you know in my practice career. I have seen kids herniate while dilated And it's not been a good experience and I've also had a number of kids Get urgent neuroimaging tests when a nurse suddenly discovered at 3 a.m That a child's pupils were as big as dinner plates And then find out that it was due to an eye exam, you know on the day before So I think that we need to work together, you know with the nursing staff make sure when we dilate pupils We have a sign put up So that when they're making their rounds if they do actually look at the pupils That they're not surprised to suddenly find dilated pupils after we've done an exam and dilated them pharmacologically Does that help with your observation Catherine because I think that that's You know that that is an important issue you brought up Yes, thank you And and you know and if you're in doubt and you're really getting pushed to make a statement about something Let that be a statement made By an attending You know, uh, you're you're welcome in any of these abusive head Trauma cases to call me and I will if I am in the country in town here Make every Uh, you know effort to get to where you are and see the kid with you and that way that You know decision can be on me and they can grumble at me because I don't care Um as long as we get the child taken care of and do the right thing for them and and and we have to I think have some perspective on You know other people's viewpoints on On on their care of the patient um What other issues are there with These abusive head trauma things that have come up or cause concern in anybody's mind I guess the one last thing I would say with that is please Leave some wiggle room In your assessment for the attending to make a statement When they come back and look at the child with you if that's what you're arranging um So that they can you can you know, I would limit your description to there are hemorrhages present You know in this location and you know and and dr. So-and-so is going to come evaluate the patient And let that be our decision so that we don't appear to be at odds over our interpretation of things Because that again is something that I have had to discuss personally in court and explain before a judge And uh, you know, I mean it's it's Discussable and I can certainly lay it out for them, but it'd be better if it looked, you know, if we tried to have a more A coordinated interpretation is at work Otherwise, I'm going to let you folks get on with your day if you need help finding that those chapters in that book Stop by clinic. Um, there should be one on the bookshelf right over where I sit and I'll be happy to Share it with you. Um, I don't think that's available electronically Are there other questions concerns about things in general? A primary that I need to be aware of in terms of anybody getting access With all this COVID stuff going on I guess it's a no I guess that's a no. Well, I'm sorry. We didn't do this in person so I could bring you all bagels, but We'll do that at some point with a future lecture and we'll Maybe be able to do this in person because I think that we if we work it out, right We should be able to do this and spread out in the auditorium To the extent that we can do Lectures and maintain social distance if that works for everybody something to think about Anyway, thank you all. Thanks for getting me through getting on zoom and doing this because it definitely is not my forte And all of these Things and let's see. How do I I guess I hit and show there we go then I can get out of there So Catherine, I'll see you about nine hopefully and everybody else have a wonderful day and Um, we're out with the five minutes of spare. Have a great day. See you. Thanks. I have to yeah Thank you It's my pleasure and this night for those of you. I haven't met stop by and say hi