As a pediatric intern at University of New Mexico Children’s Hospital, Leslie Strickler, D.O., helped care for a premature infant who spent months in intensive care before being successfully discharged.
“The next time I encountered her was when I was the senior resident in our ICU and she had been killed by her father,” Strickler says, her eyes welling at the memory.
“It was devastating,” she says. “We had poured all these resources into saving this child’s life. From an emotional standpoint it was awful – I was attached to the child and her family. This was a child who needed more, and didn’t get it.”
That experience early in her career played a role in Strickler’s decision to become a board-certified specialist in diagnosing child abuse. As medical director of UNM’s Child Abuse Response Team (CART), she is one of just a handful of physicians in New Mexico with the expertise to determine whether a child’s injuries might have been caused deliberately or by accident.
Founded in 2004, CART sees between 300 and 350 cases of suspected physical abuse in children each year, Strickler says. The team also provides case reviews or assists law enforcement in another 50 to 100 cases a year, she says.
Shalon Nienow, M.D., who is fellowship-trained in child abuse pediatrics, recently joined the team, and Karen Campbell, M.D., who also consults for the New Mexico Children, Youth and Families Department, helps out as well.
Para Los Niños, a companion program headed by Renee Ornelas M.D., handles about 400 cases of alleged sexual abuse per year, Strickler says.
The New Mexico Legislature will consider a proposal during its 2015 session to build upon the two programs by creating a new Child Maltreatment Center at UNM. Funding the proposed center would provide for hiring enough staff and clinicians to make the service more sustainable, Strickler says.
With additional resources, she says, the UNM doctors also could extend their reach to serve the entire state, providing badly needed backups for primary care physicians in rural areas. At present, it’s a stretch to handle all of the cases arising in the Albuquerque metropolitan area, she says.
Having physicians trained to distinguish accidental injuries from those caused by abuse is important, says Strickler, who also spends a substantial amount of time consulting or testifying as an expert witness in civil and criminal proceedings.
The diagnosis of child abuse became a formally recognized specialty relatively recently, Strickler says. As a student at the Chicago College of Osteopathic Medicine, “I never saw a case of child abuse,” she says. “I never got a lecture about child abuse. It wasn’t covered in the medical school curriculum.”
Coming to New Mexico for her residency, “I was just stunned by the volume and severity of the trauma that I saw,” Strickler says. “All of the injured kids were coming here. That’s what really sparked my interest in the field – the clinical exposure and then coming to know the challenges that our children face.”
Strickler, who has a young son of her own, says it isn’t always easy to deal with the horrific abuse she sometimes encounters on the job. “You have to have a certain mentality and objectivity to survive in this field,” she says. “I look at child abuse as a pediatric disease process, much as you look at cancer.”
Child abuse has occurred throughout human history, Strickler points out. “It’s something that happens, and we have to be prepared to respond,” she says. “Burying your head in the sand is not helping.”
Investigating whether child abuse has occurred is rarely a slam dunk, she says. “There’s no single injury that will walk in the door where you can say with 100 percent certainty that it’s child abuse or not.” Broken bones, bruises and even burns can result from accidents as well as abuse.
A medical detective of sorts, she works closely with radiologists and other technicians to look for subtle signs that will help make a definitive determination. “It is a very nuanced field,” Strickler says. “You have to have a good background not just in medicine in general, but also in development and understanding injury patterns.”
At the same time, she adds, “You have to recognize you are one piece of the puzzle.” Protective Services Division workers and criminal investigators can also provide additional information critical to making a determination.
Even so, 10 to 15 percent of cases lead to an indeterminate assessment – and those situations are hard on families and investigators alike, she says.
With each case, Strickler and her colleagues walk a thin line between falsely implicating an innocent party and sending a child home to a dangerous environment. Unlike other physicians, they don’t have the option of recommending a wait-and-see strategy.
“That’s not a great approach in child abuse medicine,” Strickler says. “I think it’s fair to say we often agonize over our assessments, because we want to get it right.”