“Please, Dr. Harper.”

At the computer, I clicked on all the boxes I needed: chemistry, CBC, urine, chest X-ray, liver function tests. Wait, I said to myself, I wasn’t going to order liver function tests. There honestly was no reason to get LFTs in a healthy, febrile seizure patient. But this child wasn’t waking up, so the situation could be turning into a more serious medical issue. I moved the cursor over the LFTs to unclick it, but then I didn’t. I couldn’t bring my index finger to press the button down.

Something just felt wrong. I had no good reason to suspect badness here; after all, apart from her semiconscious state, the child had a normal exam.

The dad, who was now at the patient’s bedside after we had completed our initial evaluation, appeared to be appropriately concerned as he caressed the child lovingly between medical interventions. The stories he’d given to the rapid-response team and to Jaya were consistent, but I decided to go ahead with the test anyway. There were greater crimes than adding one extra, non-evidence-based test to a pediatric patient’s evaluation. Perhaps there was some metabolic issue that LFTs would help elucidate, I said to myself, knowing full well that this was untrue. I signed my orders and waited.

“Dr. Harper, we might as well get this kid ready for transfer. Even if it turns out to be a simple seizure in the end, she’s not waking up, so she needs to go to a pediatric hospital for further testing and observation,” Jaya said.

“One hundred percent agreed, Jaya. And this is why you’re one of my favorites.” I smiled.

“So far, we know her exam, vitals, blood sugar, and urinalysis are negative. Her chemistry is fine, too. Her X-rays are pending. I’ll call the Children’s Hospital now for transfer,” Jaya said.

As Jaya went to do that, Dr. Berry, the attending working the fast-track section of the ER, approached her to see if she would be interested in helping with the reduction of an acutely dislocated shoulder when we finished our case. I told Jaya I’d finish the calls and paperwork on our case so she could complete the joint reduction with Dr. Berry.

Minutes later, when Jenny’s X-rays came in, I looked at them. Pediatric films can be challenging because a child’s bones are immature, but nothing acute jumped out at me: clear lungs that were well inflated with no pneumonia, fluid, or pneumothorax. Her CBC and chemistry were unremarkable. The patient had been accepted to the nearest children’s hospital, which was conveniently less than a mile away. The hospital was sending its ambulance unit to pick her up. Seconds later, EMS bundled the child back onto the gurney to leave. I clicked back into her chart and saw that her LFTs had just come back: They were five and six times the normal limits. Just as I registered concern, I got a call from radiology.

“Hello, Dr. Wechsler of Radiology here. Do you have the child just X-rayed for febrile seizure?”

“Yes, baby Jenny.”

“Okay. No source of infection here, the heart and lungs look good, but there are fractures. Looks like different stages of healing. Mostly old and well healed. Possibly one or two newer ones, I can’t say that for sure, but I can say this is not good.”

I looked back to see the gurney rolling out of the department, the father following close behind, his face twisted in fright, his knit hat clenched in his fist and drawn close to his quivering lips as he asked the paramedics if his baby would be okay. Her mother had arrived and was being comforted by an older woman who appeared to be either her mother or his. The family trailed out behind the gurney of the child who was broken by one if not all of them.

“Thank you, Dr. Wechsler. This is bad, very bad. I’d better call Children’s Hospital to update them before the patient arrives.”

I called the accepting physician, whom I had spoken to just minutes earlier. “Dr. Pierre, Dr. Harper again. I want to give you a terrible update. The child is on her way over to you. Just as EMS rolled her out the door, I got these last two pieces of information. Her LFTs are significantly elevated, and she has multiple rib fractures on X-ray. I’m really concerned this child’s altered mental status is the result of blunt trauma, probably liver injury from blunt trauma as well, which explains why the LFTs are through the roof. She certainly needs a trauma workup. I’m sorry.”

It was possible the child had some critical metabolic issue that had led to liver failure and recurrent seizures. It was possible those fractures were from those same seizures and had gone undiagnosed. Yes, that was all possible, and there are case presentations written on this very phenomenon. There are also times when your gut tells you otherwise, when you’re in the presence of another body and can’t help but feel its energy and hear the whisper of its silenced story. This limp, semiconscious child had been beaten—beaten to convulsion, beaten to fracture, beaten to a bleeding liver.

“Got it” was Dr. Pierre’s response. The accepting doc at the other end of a transfer call never says much. The case isn’t real until it arrives. The information isn’t true until it’s verified. Right now, my call to her was only adding to her workload, so “got it” was a reasonable response. Plus, we ER docs stand witness to human suffering too frequently. It was draining and depressing, and often left us with only enough hope to muster those two words.

So, days later, when the update came that the father had been charged with abuse, that he had caused the retinal hemorrhages, cerebral contusion, multiple fractures, and liver laceration, we couldn’t say we were surprised. It wasn’t because he “fit the part,” whatever that means. My snapshot of him in the middle of the ER hadn’t fit any particular stereotype. No, we weren’t surprised because this is what we do. I imagine every forensic examiner has the same reaction. It’s horrifying and sad when you realize something terrible about another human being, yes. But—and this is a disturbing commentary on humanity—it can no longer be called surprising. It wasn’t yet known if the mother, who had stood by for the past twenty-two months as he abused their daughter, would also be charged: The calculation as to what extent the “bystander” is complicit, it seems to me, is always complicated and often tortured.

As I ended the call with Dr. Pierre, Nurse Carrenza approached me.

“EMS just rolled in a respiratory arrest that they intubated in the field from a nursing home. Only the rotating dental resident is in there now, so we could really use you.”

“Of course,” I said as I followed her to Room 20.

As I entered the room, one paramedic was bagging the patient and a tech was doing chest compressions. One nurse was placing the patient on a monitor, and another was obtaining a second IV; EMS had already placed one.

“Hello, all. I’m Dr. Harper. What’s the story?”

“Hey, Doc. Ms. Mary Giannetta is a seventy-eight-year-old woman with diabetes and a heart condition,” one of the paramedics explained. “She was in distress at the nursing home. Actually, her family found her and alerted the staff. Did the nursing home call for notification?”

We all shook our heads.

“Geez. Of course not.” The paramedic sighed. “When we arrived, she was barely breathing, and then lost what thready pulse she had. PEA on monitor. Unknown downtime. She’s been with us about fifteen minutes and has had three rounds of epi. The last dose was given approximately one minute ago. Accu-Chek two-fifty. We put a twenty-gauge in her right AC and obviously intubated in the field.”

“Thank you. Y’all did everything,” I said as I walked over to Ms. Giannetta’s right side. “Now that she’s on our monitor, can we hold CPR to get a pulse check and switch roles so EMS can be on their way? Respiratory, please hold bagging, too, while I listen to the chest. No breathing, no breath sounds.” I placed my second and third fingers on the patient’s carotid artery while watching the monitor. “No pulse.” One slow line snaked across the screen with mild variations. “PEA. Please resume CPR with compressions, bagging, and let’s give an epi.”