MD, MPH, FAAP
Dr. Mandy O’Hara is a child abuse pediatrician in New York City and a frequent contributor to the LitMed Magazine. She leads Wellness efforts in her regional and national professional societies. Her research and educational efforts focus on provider wellness in the face of secondary traumatic stress.
Angelica arrived on time with her foster mother, aka Grandma, as she had the good fortune of kinship support when her parent was deemed unfit for her care. Physically abusive welts and bruises had been documented with flash and photo in the Emergency Room as her life changed forever, for the better one hopes, as she left her father’s care. It was her second life experience of separation by age 12, as her mother abandoned her in her early years. And now, who knows her father’s true intention to care for her alone as a single dad, but her skin bore the marks of abusive parenting compounding her history of maternal neglect, with a safe removal necessary for her survival.
I reviewed the photos, taking note of form, dimension, and bodily location of the marks on her back, in preparation for her follow up, as I assumed responsibility of being her assigned CAP (child abuse pediatrician). It was luck of the draw who was on call that night and fortunate that she came into my care.
Working in service to the hospital, child protection, detectives, and the court, I show up with my own intention: to apply evidence-based medicine to the best of my abilities, in hopes of altering the trajectory of a child with adversity toward less harm, and the potential for healing. And… to show up fully present, for each and every one, including myself.
Angelica walked with me to the exam room, as we began the visit. Just on the cusp of adolescence, she came dressed in bedazzled jeans, a colorful shirt, and high-top sneakers, with hair and jewels topping it off. Her care for style and fashion stood out and presented an opportunity for a first compliment from me to her. We began to connect.
After obtaining a gentle history from this young pubescent, I offered her the crunchy blue paper gown to change into for her exam, reminding her that she put it on with the opening in the back.
Now this was no “gown” for a fashionista like her. Rather, it was a stiff formless sheet of crepe with holes for her arms and a plastic strip for a belt, all bound to tear at some point before the end of the exam. She connected with me now and spoke. “I don’t want to put it on.” Understandable, I think, as I try to relate to the pain on all levels she experienced the last time she put on a hospital gown in the Emergency Room. Was I trauma-insensitive, despite striving for the contrary, by asking her to put it on with the open in the back, as her back was the main location of the pain of her inflicted wounds? Yet I’m her child abuse pediatrician, and I couldn’t neglect her exam. Gathering up kindness and understanding, I asked again if she would change into the gown, telling her that I understand she did this before when it must have been very difficult, and I am here now to see how the healing has begun. Both reluctant yet agreeable, she changed behind the decorative curtain in the corner of the room, and I waited, ready to continue our connection.
The exam began, as I often say, “from head to toe” because “I care about every part of you—even your toes.” I saw her earrings, heard about her favorite color, and felt warmth developing in the room. The opening of the gown allowed me to see complete healing of the skin wounds, which I tell her, reminding her how her body heals and is strong. To my dismay, as we get to the heart, face to face, she smiles and says to me “I like this gown.” What? I think! Just moments ago, this fashionable
12- year-old had no interest in putting on that bulky paper gown, so surely she didn’t mean that she actually likes it now. I took pause for a moment, in our moment of connection, and I realize what she was really saying was “I feel comfortable now…I feel cared for in this moment, in this paper gown.”
These are the career-defining moments that support the sacrifice, the stress, the trauma, the sleep deprivation, the juggle, and everything in between in child abuse pediatrics practice. Feeling in that moment, that I made a neglected and abused child feel comfortable and cared for-even if just for now- I imagined a synapse reconnected away from her over-worked amygdala. As we know, neural connections have embedded her trauma history into her biology, defining most experiences as unsafe. When a new safe and nurturing experience is supported in a trauma-exposed child, healing unfolds through new neural connections, one at a time. Maybe in this brief moment, just one neuron realigned toward resiliency in the infinite branch of cells in her brain. However small a single neural reconnection may seem, the significance of connecting with a traumatized child in a safe and nurturing way itself felt immense.
Angelica’s ability to connect safely and securely in the present moment with me, despite her upbringing, was likely mostly because of Grandma, and the systems in place that brought her into a new home, opening doors for more moments of security like this. My experience was one of gratitude that I was able to be fully present in our connection and see this synaptic change unfolding. My gratitude may have stemmed, perhaps too, from my own adverse childhood experiences that enable me to see, hear, and feel for my patients in a way I would not be able to, if not for my upbringing, as it were. I felt my own neurons realigning toward a more optimistic belief system that trauma has purpose and heals. I felt another neuron in my brain connect me deeper with my efficacy as a physician. With systems and processes now protecting her, our connection that day protected me–from the risk of physician burnout or compassion fatigue when we can no longer see the moments when healing truly occurs. Together, that day, Angelica’s checkup was not only healing her….it was also healing me.