Transcript of the Louder than Silence Podcast Episode #8: 25 People That Could Have Saved A Baby 

Transcribed by Adam Soisson 

[Inspirational theme music plays.] 

>> Lori: Thank you for joining us. In this podcast, we are real people, talking about real things. Child abuse and neglect: a topic that is all too often left in the shadows of silence, leaving survivors alone, fearful, and oftentimes without a voice. We’re having conversations to become louder than silence. It is here, where we will invite you to join us and be the change needed to end child abuse and neglect.  

>> Dick: This is Dick Krugman, I’m Chair of the Board of the National Foundation to End Child Abuse and Neglect, also a pediatrician for the last 50 years and my career in child abuse and neglect has a lot to do with a man named C. Henry Kempe. Henry has a book written about him by one of his daughters, Annie, so if anything I say in this podcast makes you want to learn more about him, the book is called A Good Knight for Children by Annie Kempe. Henry was a pediatrician, he was Chair of the Department of Pediatrics here at the University of Colorado School of Medicine and in 1962 he wrote with several other colleagues what is called a landmark paper by the American Medical Association entitled The Battered Child Syndrome. It was that paper and Henry’s work that led to this country’s recognition of the problem of abuse that we were ignoring and not dealing with. It was Henry’s work that led to every state passing mandatory reporting laws for those who suspect abuse and are professionals working with children. He did that in the late 1960s and in 1972 he started a center called the National Center to Prevent Child Abuse and Neglect. Actually it was the National Center for the Prevention and Treatment of Child Abuse and Neglect and it was located here in Denver. Henry’s work spanned 20 years in this field yet his background was in pediatric infectious disease. He was very involved in smallpox research and the research around a measles vaccine. I actually first heard him speak when I was a medical student at New York University in 1967 when he gave a talk titled The Battered Child Syndrome. I came home that night as a medical student and said to my, at that time, young wife. We had been married for about nine months. I said, “I think I want to go to Denver for my internship because this guy Henry Kempe is an amazing person.” She said, “Well you promised me water. Denver doesn’t have any water.” So I said, “Well let’s see how it goes.” So in the summer of 1967 we took a quick trip around the country looking at internships. Denver was the first stop. We then went to Seattle and San Francisco and Stanford and LA, all of which had a lot of water nearby. As it turns out I wound up here in Denver for my internship and we started here in 1968, June 23 was the first day. I saw my first case of child abuse on December 1, 1968. I was an intern in the emergency room at Denver General Hospital and at 9:00 at night a young mother brought her baby to the emergency room and said she had been at the movies with the baby and when the lights came up she noticed that the baby wasn’t breathing so she brought him to Denver General. When we examined the baby, the baby was very dead. The next morning the Denver coroner examined the baby and we found 12 rib fractures, skull fractures, brain injuries and a ruptured liver and spleen in the abdomen and it was clear that the baby hadn’t just stopped breathing, the baby had been severely beaten.  

Henry Kempe asked me to spend the next week looking into the medical records at Denver General and at Colorado General Hospital for that mother and baby because he wanted me to present that next Friday afternoon at a conference that we called the CPC, Clinical Pathologic Conference, where when we think mistakes have been made we learn from our mistakes in medicine. So I spent the next week looking at the records and I presented the case. It really started where this woman, the mother, in the 8th month of her pregnancy had a knock on her door. In 1968 in Denver, every newborn baby was visited the day after it got home by a public health nurse and a public health nurse was visiting a baby and mother in this particular apartment building and the mother said to the nurse, “you know I’m worried about my neighbor. I think she is about 8 months pregnant and I don’t think she’s gotten any help and she seems to be depressed.” So the public health nurse knocked on the door, she grabbed the mother by the hand, she said, “we’re going to the hospital to get you checked.” When they got to the hospital at Colorado General in the OB [obstetrician] clinic the note said, “Depressed mother, no prenatal care. Has only gained 15 pounds during her pregnancy. Seems to need help. Referred to social worker.” Now the social worker was sick that day so they gave the mother the appointment to come back the next day and the next thing on the chart said she missed that appointment. The next thing in her chart was a month later when she came into the emergency room and she was in labor. She delivered her baby and for the next three days was in the hospital. That’s how long we kept people in the ‘60s. The nurse’s note said, “she seems to be depressed. She seems not to be very interested in the baby” and they worried about her and they sent her referral to social work at Denver Social Services and a public health nurse. The next note in the chart came back from the social worker that said, “Denver Social Services says there’s no abuse yet so there’s nothing we can do.” The public health nurse note came back and said, “there’s no answer at the door.” The next note in the baby’s chart showed that at two weeks of age the mother brought the baby to the emergency room at 11:00 at night and said the baby has a rash and she wanted to have the baby’s rash taken care of. A colleague of mine who was the intern wrote a very short note in the chart which said, “subjective: mother says the baby has a rash. Objective: I examined the baby, there was no rash. Assessment: well baby. Plan: 1) Gave her a lecture on the appropriate use of the emergency room and 2) told her to come back to see a dermatologist if the rash comes back.” The next note on the chart was a month later and the baby was seen in the pediatric clinic by a third year medical student. Like many medical students there was a five page note. Two pages describing the history and a page and a half of physical exam. The assessment for this baby was that the baby had an upper respiratory infection, a cold and the plan was to use saline nose drops, a bulb syringe, and come back if things get worse. One of the things the medical student noted but wasn’t discussed was that the baby had two small bruises on the right arm and some linear bruises, longer bruises on his chest. The attending who checked out the baby agreed with the above and signed his name. The next note on the chart was a month later when the baby came in and the mother said he hadn’t been moving his right arm for two days. An X-ray showed that the baby had a spiral fracture of the humerus which is the big bone in the upper part of the arm. He was admitted to the hospital and a report was made to Denver County. A police officer by the name of Sam Wood came out to see the baby, said it looks abuse. He referred the case to Child Welfare. They didn’t take reports unless police gave it to them in those days and they sent a worker out to the home and the next day the report came back that the house was neat and clean. It was okay to send the baby home and the baby was sent home. The next time the baby was seen was when I saw the baby dead at Denver General emergency room. 

Through this whole story Henry was putting marks on the blackboard and at the end of my story there were 27 marks. The 27 marks each represented a professional who, in his view, could have prevented the death of this baby. Only two of the 27, the public health nurse at the beginning and Sam Wood, the policeman, did their job correctly. Everyone else completely failed in recognizing this was a mother desperately in need of services before she killed her baby. That made a huge impression on me, not just the behavior of the mother who would do such a thing to her baby but the behavior of society, professionals, that would ignore it. So I kind of got intrigued by child abuse as an area and for the next three years of my residency I saw a lot of cases but I came back to the Department of Pediatrics in 1973 after two years in the [military] service. I found myself doing this work, covering for Henry when I could. Eventually, in 1980 he asked me to be Director of the [Kempe] Center. So that’s a brief history of my first case and this is Dick Krugman. 

[Inspirational theme music plays.] 

>>Lori: I want to thank each of you again for joining us today and listening in. If you or someone you know is being abused, please call 1-800-4-A-CHILD. To learn more about EndCAN, visit www.endcan.org or find us on all social media platforms. Join us in being Louder than Silence and being a part of the change. Please leave a comment, like our podcast, or share with your friends. The more the word spreads, the more of a collective impact we can have. If you have a question or you know someone who would want to be a guest on our podcast, please contact bethechange@endcan.org. Thanks again, and have a great day.  

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