Suspected Abusive Head Trauma in an Infant
An optometrist in Bismarck examines an 8-month-old infant brought in by his mother for 'crossed eyes.' The infant is fussy but afebrile. Dilated fundus examination reveals bilateral, multilayered retinal hemorrhages extending to the ora serrata, with no external signs of trauma and no history of accidental injury. The mother says the infant was with the father's new partner the previous evening and 'may have bumped his head' but cannot provide details. The optometrist has no pediatric ophthalmology equipment beyond an indirect ophthalmoscope and no ability to order neuroimaging. The father arrives and demands that the examination stop and that no information be shared with anyone. The optometrist's staff asks whether the practice should call the police or child protective services. The child has Medicaid, and the parents are separated.
1. Does the optometrist have a mandatory reporting duty, and how quickly must the report be made?
Read the worked answer
Yes. Bilateral, multilayered retinal hemorrhages in a nonmobile infant, without a credible accidental mechanism, are a red flag for abusive head trauma. North Dakota mandatory-reporting law requires a licensed health care provider who suspects child abuse or neglect to report promptly to child protective services or law enforcement. The optometrist does not need to confirm the diagnosis or identify the perpetrator; suspicion is enough.
The report should be made immediately, not after the parents leave and not after a second opinion. The optometrist should also arrange urgent pediatric ophthalmology or emergency department evaluation for the infant's eye and neurologic status. HIPAA permits disclosure for suspected abuse and for required reporting. The practice should not delegate the report to the parents or assume that someone else will call.
2. What should the optometrist tell the parents, and what should be documented?
Read the worked answer
The optometrist should tell the parents that the findings are serious, that the infant needs urgent specialist evaluation, and that a report is being made as required by law. The message should be factual and non-accusatory. The optometrist should not investigate, interrogate the parents, or promise confidentiality that cannot be kept.
Documentation should include the objective findings, the infant's behavior, the mother's exact statements about the previous evening and the 'bump,' who was present, the time the report was made, the agency contacted, and the referral plan. Record verbatim statements in quotation marks rather than conclusions about who caused the injury. Note the father's demand to stop and any safety concerns. The record should be complete, timely, and not altered later. The optometrist should continue necessary care until the infant is transferred.
3. The father demands that the examination stop and that no information be shared. How should the optometrist respond?
Read the worked answer
The father's demand cannot override the mandatory reporting duty. The optometrist may stop non-urgent examination steps if continuing would endanger the child or staff, but should not withhold the report. If the parents attempt to leave with the infant before urgent evaluation, the staff should call for assistance and report the safety concern. The child's Medicaid status and the parents' separation do not change the duty.
The optometrist should explain calmly that the law requires a report and that the infant needs emergency evaluation. Document the father's statements, the time, and any refusal of care. Consent for emergency treatment and reporting are separate issues; mandatory reporting does not depend on parental consent. The priority is the infant's safety, followed by an accurate record and cooperation with the investigating agency.