Unforgivable

ONE

It took several moments for the constant beeping to penetrate Emily’s deep sleep. She rolled over and grabbed her beeper from the nightstand. The indicator light glowed the number of the ER department of the hospital. Slipping into her robe, she grabbed the phone and pressed the button preprogrammed to the Scottsdale Memorial Hospital ER. Gina, one of the triage nurses, picked up after several rings

It’s Emily. What’s up? Emily asked, trying to clear the sleep from her voice.

We need you now, Emily. How fast can you get here? Gina asked.

Just give me ten. Emily hung up the phone, sensing the tension in Gina’s voice. Gina was one of the seasoned triage nurses at Scottsdale. Emily knew something really bad had happened if she was flustered.

Emily rushed into the bathroom off her bedroom. Splashing water onto her face and neck, she stared at her reflection in the mirror, attempting to center herself, building courage for the crisis to come. Emily was one of the few social workers left at Scottsdale Memorial Hospital. Due to the budget cuts at the hospital and structure changes with Medicare and insurance companies, the social service department had gone from a competent staff of twenty to an overwhelmed staff of three. Tonight was one of the three nights a week she was on call.

Returning to her bedroom, Emily pulled on the slacks and blouse she’d abandoned on her wing chair when returning home from work earlier. Racing through the condominium, Emily grabbed her keys and purse from the antique hutch next to her front door. Locking the door behind her, she headed for her attached garage at the end of the hallway.

Normally, she would have walked to the hospital; it was only two blocks from her home. But because of the late hour, she climbed into her late-model Jeep Cherokee and backed out of her garage.

In the short distance to the hospital, Emily wondered what tragedy awaited her there. In Emily’s job, she dealt with the worst side of human nature. Most of her ER calls were the result of domestic violence, rape, and child abuse. Once in a while, she was lucky enough to get away with just writing a voucher for a cab, or a voucher for a local motel for a member of the huge population of homeless in Weber County. The calls that disturbed Emily the most were the ones involving child abuse—she dreaded interviewing children who were bulletin boards for the horror inflicted on their little bodies. Even worse were their eyes—eyes that never showed the wonderment and joy so obvious in other children. The eyes of the abused children, in contrast, appeared empty and were filled with more pain than most adults experienced in a lifetime. All of Emily’s cases were about people hurting one another, but the ones involving children left the deepest scars on her heart.

As she drove into the ER entrance, Emily spotted Fred, the night security guard, waiting to park her car. Fred smiled as he opened her door. There must be a full moon tonight; this place is packed.

Thanks, Fred. I’ll let you know when I’m ready to leave, Emily said.

Passing through the automatic doors, Emily glanced to her left. Fred was right. Not only were all the waiting room chairs filled, but people were stacked against the wall as well.

Gina came out from behind the intake desk as Emily entered the treatment area. Taking Emily’s purse, Gina said, It’s really bad in there. I’ll get you some coffee.

At the main desk, two nurses Emily did not know very well were waiting for her. Both had recently graduated from nursing school and were new to Scottsdale Memorial. As she got nearer, Emily could see one of the nurses had been crying; her face was streaked with tears. We screwed up! was all she could manage before she burst into loud, rasping sobs.

Okay, first take a deep breath and calm down. Emily glanced at her nametag. Keri, with an i. She looked about twelve in her current condition.

I’m Kathleen, the other nurse introduced herself. She looked about thirteen.

Emily steered both women into the medication room. Kathleen, why don’t you explain what’s going on while Keri composes herself.

Around nine, a baby came into the ER via ambulance. The paramedics reported that the baby had been found not breathing in her crib. Her voice dripping with judgment, Kathleen continued, The mother and her boyfriend came in with the baby."

Which unit brought her in? Emily inquired.

Number twenty-four. Charlie and John were on tonight. That particular crew was very experienced, and like Emily, they had seen it all.

When they arrived at the house, the boyfriend stated that when he went to check on the baby, he found her facedown in the crib. When he realized the baby was not breathing, he dialed 911. Emily could hear the catch in her throat as she continued. But when Dr. James asked him what happened, his story changed.

Dr. James was one of the best pediatric neonatal doctors that worked at Scottsdale.

"He told Dr. James that when he went to check on the baby, he found her face down beside the crib. It was obvious that the circumstances were questionable."

What’s the baby’s status now? Emily asked, not really wanting to know, sensing the answer would not be good.

The baby’s critical. They are going to air transport her to Christian Children’s Hospital.

Emily nodded. Where are the mother and her boyfriend?

The nurse barely met Emily’s eyes. They have already left to meet the transport.

Is it fair to assume that the police have already questioned them?

Well, that’s why Keri is so upset. The tension in Kathleen’s voice caused Emily’s stomach to tighten; she already knew what was coming next.

When the baby came in, she was critical. Things went so fast. Now Kathleen began to shed a few tears of her own. We forgot to call DCFS. Kathleen finally got the last words out.

The Department of Children and Family Services is a government agency that investigates any indication of child abuse and/or neglect. The agency is contacted immediately in any suspected case of abuse. Besides investigating the report, they also work with the police and other agencies in investigation and follow-up services as needed.

Emily tried to keep her voice calm. When did you contact them?

About twenty minutes ago, right before we called you, Keri replied in a very soft tone.

Emily glanced at the clock; it was now 1:02 in the morning. Four hours had passed since the baby had first arrived.

What county does the mother reside in?

Jackson, Kathleen replied, unsure why Emily was asking.

The police are required to contact DCFS in this kind of a call. Emily hoped that was the case for their sake. There may be a case manager en route, and you are just not aware of it. Emily glanced toward the front desk. Where is the investigating officer? I’ll check with him.

Keri lowered her eyes, and Kathleen’s voice cracked. He left a while ago.

The beginning of a tension headache crept into Emily’s neck. Let me get started. Find me before you leave. Emily started to walk away, and then turned to ask, Who is the charge nurse on tonight?

Still fighting to hold back her tears, Keri replied, Diane.

Emily was burning with anger. When the hospital had made the decision to downsize the social service department, the nurses were given responsibility for the first call contact to DCFS—a function that had previously been held by the crisis intervention worker, and with good reason. A nurse’s first responsibility is to her patients and their medical needs. The nurses were never trained to handle networking outside the hospital. This case was a perfect example of the negative ramifications of current policy changes—policy changes that Emily had fought since their origination.

Emily headed down the treatment hall—chidingly known as the War Zone to the Scottsdale ER staff. She glanced into each treatment room trying to locate Diane. Suddenly, Diane called out to Emily when she was just outside treatment room four. Room four was reserved for the worst trauma cases received in the ER.

As Diane approached, the tension was evident on her face. Did you talk to Keri and Kathleen? Diane asked.

Yes, was Emily’s only reply; it was clear she wanted Diane to explain.

The girls should not have had primary in this case; they are too new and don’t have enough experience, Diane confessed. When I found out, I contacted DCFS immediately. When Emily didn’t answer, Diane continued on. They have not returned my call yet.

How long before transport? Emily inquired.

They are getting the baby ready now. Come in and take a look.

Both women entered the treatment room. The harsh florescent lights reflecting off the stainless steel hurt Emily’s eyes. The floor was littered with instruments and discarded plastic wrappings from the many treatments that had been performed. In the center of the room, the unconscious baby was restrained on the treatment table. As Emily approached, she noticed the baby was tubed to assist with breathing. An IV was inserted in the right arm, held to the restraint with a small board to keep the IV in place in the event she should regain consciousness.

Blinking back the tears filling her eyes, Emily asked, Is she stable enough for me to do my exam?

Yes. I’ll get your camera, Diane replied, leaving the room to retrieve Emily’s digital camera from the front desk.

Emily asked the treatment nurse to take off one of the baby’s restraints so she could see her backside. Because of all the tubing, the baby wasn’t gowned. There was apparent bruising forming a chain around her neck. On the edge of the bruises there were tiny red marks. She also had a large hematoma on the left side of her forehead and temple. Diane returned to the treatment room, camera in hand. After giving Emily the camera, she remained beside her to assist her with positioning the baby. Emily shot pictures of the injured areas about the head and neck. Diane lifted the baby gently and turned her so Emily could see her back and legs. The bruises on her back were older. The coloring was murky and in several different shades, and the yellowing at the outline was a sign of healing. There were several markings on the backs of her legs, which appeared to be second-or third-degree burns. Those burns were angry red and looked to be pretty recent.

You can lay her back down, Emily said, shattering the eerie silence that had settled over the treatment room.

Emily moved to the end of the table and examined the baby’s feet. Often in child abuse cases, the feet are vulnerable areas. They tend to heal quickly and are not openly visible. Again, there were old wounds. Emily could see a faint line curved at the end. Coat hangers are common weapons. Small, round scars were evidence of cigar or cigarette burns as well.

Did you document these injuries on the full-body chart? Emily asked Diane.

Diane nodded. We also did an infant rape kit, Diane continued, struggling to keep her voice even. When we undressed her, we found some markings in the genital area.

Jesus, was all Emily could manage.

Okay, I think I’m finished. Emily had taken close-ups of all the baby’s injuries, as well as a full frontal photo.

"Diane, can you get the officer who responded to the call on the phone for me please? I’ll be in the coffee room reviewing her chart.

Emily left the room and headed for the front desk where she used the phone to contact DCFS. She left a message for the night supervisor to return her call.

Gina, if DCFS or the police return my call, will you patch them through to the coffee room? Emily asked.

Sure, Emily, here’s your coffee. The nurse handed her a powder-blue mug filled to the brim with coffee sweetened with two Equals, just the way Emily liked it.

Emily grabbed the baby’s chart and her steaming cup of liquid caffeine, and headed toward the coffee room. There were no offices available for social service in the ER. A small table; an old, faded, brown leather chair; and a phone shoved into the corner of the coffee room served as a work area. When her work required computer access, she was forced to fight for time on one of the half dozen computer terminals sprinkled along the hallway.

Emily ran her fingers through her hair as she sank into her chair. She caught a glimpse of herself in the mirror above her desk. She looked tired. To her, her features were plain. She had a soft, oval face framed by sandy blonde hair that hung past her shoulders. Her eyes were clear and piercing blue, tipped with dark, long lashes. Emily felt her full lips conflicted with her slender nose. She was tall and lean from hours spent in the pool. Most of the time, she swam as a way to relieve tension rather than from any desire to keep in shape.

Turning away from the mirror, Emily directed her attention to the baby’s chart. Depressing the record button on her machine, she began to dictate: The patient is a twenty-three-month-old female. She resides with her mother and her maternal grandparents. The baby’s father currently lives in the area and practices regular visitation. The baby has no pertinent medical history, although she was seen last week by her pediatrician for the burns on the backs of her legs. The chart indicates that she was brought into ER in full cardiac arrest. The EMTs had revived her once at the home, and also during transport. The boyfriend stated on scene that he went into the baby’s room to check on her and discovered her face down, not breathing, in her crib. He then contacted 911, and called his girlfriend on her cell phone. When further questioned by the two EMTs about the bruising about the baby’s face, he recanted his original statement. He claimed that when he went to check on the baby he found her face down next to her crib. He assumed the bruises were because she had fallen out of her crib.

The phone interrupted Emily’s dictation. ER. This is Emily, she answered.

This is Laura Evans. I’m the night supervisor on the DCFS hotline, a smoky voice replied.

Emily began the story she knew she would repeat uncountable times tonight. My name is Emily Martin. I’m a crisis intervention case manager at Scottsdale Memorial, in Scottsdale, Oregon. I’m calling because we had a twenty-three-month-old present to our ER in full arrest. Emily continued on, not needing the baby’s chart, as the details were now imprinted in her mind where they would remain like a scar on her soul. The baby was under the care of the mother’s boyfriend. The boyfriend, identified as Mark Mason, initially stated that he went to check on the baby and discovered her face down in her crib, not breathing. Emily continued with the details of this event and explained the signs that indicated previous abuse.

Okay, I’m filing a report, Articles 23 and 24, Laura stated.

Can you also run the family for previous reports? Emily knew from past experience that unless she specifically requested this step, it was often overlooked. Can you give me an ETA on a DCFS case manager?

One will respond within twenty-four hours, the case manager droned on, giving Emily the standard jargon.

That’s not acceptable, Laura. I need someone out here now. This baby is critical.

If the baby’s critical, then she’s certainly not going anywhere.

Emily attempted to calm down to prevent herself from responding in a slew of obscenities. DCFS case managers had seen the worst of the worst. Because they became entrenched in so much horror, they tended to be disconnected. It didn’t help that the ones who truly cared left within the first year because they couldn’t stomach the job. Emily didn’t accept that as an excuse, though, not when it came to kids. Someone suffering from burnout should not be making decisions that could threaten the life of a child.

The circumstances in this case warrant a case manager being here as soon as possible, Emily replied, the strain in her voice just below the surface.

If the baby is not in imminent danger, we are only required to respond within twenty-four hours, the intake worker continued to argue.

We can handle this in one of two ways, Emily responded sweetly. You can make arrangements for someone to come out immediately, or your supervisor can call me in the next half hour. Emily could become a bulldog fighting for his place at the dinner bowl when she was backed into a corner.

Fine, I’ll see what I can do! Laura responded, making no attempt to disguise the contempt in her voice.

Thanks so much for your help. After I finish up my report, I’ll give you a call back, and you can let me know who’s en route. This made it clear to the case manager that she wasn’t going to back off.

She was rewarded with a harsh click of the phone as it was disconnected from the other end.

Well, I just made another friend, she muttered, returning to the baby’s chart.

The mother’s name was Susan Germaine, twenty-three years old. She had been enrolled as a full-time college student up until six months ago. She was unemployed, Emily noted. Both of her parents lived locally, and she currently lived with them. She still went by her parents’ name, so she had either divorced the baby’s father or hadn’t been married to him in the first place.

The chart listed her home number as well as her cell phone number. Emily dialed the cell number, hoping to catch the couple before they arrived at the hospital to which the baby was being transferred.

A female voice picked up after only one ring. Hello.

Sue?

Yes, this is Sue. Emily could hear raw fear in her voice.

My name is Emily Martin. I’m a crisis intervention case manager at Scottsdale Memorial Hospital. Your baby, Sara, is just about to be transferred. Her condition has not changed. Emily updated the mother on the details of the transport.

I would normally talk to you at the hospital, but you were gone before I arrived. Emily clarified who was driving the car before she continued. I know this is very difficult for you, but I need to get some information from you as soon as possible. Since your boyfriend is driving, I would like to do that now, Emily explained.

Okay. Sue’s voice was timid, and Emily wondered if she had a sense of what this conversation was going to focus on.

Emily began by asking a few general questions, and then she plunged ahead. Upon examining Sara, I noticed some marking on the backs of her legs that appeared to be second-degree or third-degree burns. Could you tell me how Sara got those?

She was at home with me last week. I had my cup of coffee on the end table, and she tipped the mug over before I could reach her. Sue’s voice was rigid with tension. She had already adopted the defensive attitude that many parents assume when they find themselves being questioned by Emily. This was a common reaction for parents whose children were present in the ER with injuries that signaled social service intervention. Burns, spiral fractures, linear markings, and genital soreness or apparent injuries were red flags that were investigated by one or more agencies.

Emily could understand the resentment parents felt toward her and her coworkers. There was nothing that could more quickly break parents’ hearts than someone implying that they intentionally harmed their own children. But in general, it was a misconception that parents were wrongly accused and their children were taken from them without damning evidence. In fact, the exact opposite was more the truth.

Emily had lost count of the times children had been returned to home environments that were directly responsible for their declining physical and mental health. Or worse yet, there had been no intervention whatsoever into a family structure that would make a hardened criminal’s cheeks blush scarlet.

Did you seek any medical treatment for Sara’s burns? Emily inquired.

She was seen by our family doctor, Dr. Cohen. He said the burns were not that bad. He told me to keep them clean and dry and gave me some cream, Sue replied with little defiance in her voice.

Has Sara had any other medical conditions? Has she ever gotten hurt, broken any bones? Emily asked, automatically probing for any other pertinent injuries.

She fell and broke her arm about six months ago.

How about ear infections? Yeast or urinary infections? Emily wanted the answer to the last two questions more than she did the first. Yeast infections, urinary infections, and genital irritation can be telltale signs of continuing sexual abuse.

Sara has had some urinary infections, but I have those a lot too. Sue was already showing uneasiness with where Emily’s questions were focusing.

How many people live in your home?

My parents, myself, and Sara, Sue answered.

And I understand you do not work outside the home. You were shopping with a girlfriend when Sara was hurt. Who usually cares for Sara while you’re out? Emily could hear a commotion just outside the break room door. It sounded as if one of the overnight guests sleeping off his binge might be getting out of hand. Poor Fred really had his hands full with the crowded ER tonight.

Sue’s response brought Emily’s attention back to the case on hand. Most of the time, Mark stays home with the baby. He’s not working right now.

What exactly did Mark say happened tonight?

Sara was sleeping when I left. He said he went to check on her, and . . . Sue’s voice dropped off, and Emily could hear her starting to cry. He said he found her on the floor, facedown next to the crib!

Emily wondered how much time Sue and Mark had had alone together . . . time to get their stories straight. Emily fumed, thinking about the ineptness of the players in tonight’s game. So many things had gone wrong tonight. Not following the normal process might have thrown a wrench in this case if it turned out these people had anything to do with harming the child. Emily usually followed her gut. It was almost never wrong. Her gut was telling her she had much to worry about.

As part of my job, I need to ask you some questions that are probably going to make you uncomfortable, said Emily. But you need to understand that when a child presents in the ER with the types of injuries Sara has, there will be an investigation.

Emily had always tried to be up front with her clients whenever possible. She didn’t agree with the back door approach many caseworkers chose. They acted as if they were on the parents’ side, because they didn’t want to deal with the typical reaction received from this type of questioning. Her experience had been proof that the more honest she was, the more she was able to gain the information relevant to the case. Most people recognized the implications of her questions and resented her if she placated them.

Have you or Mark ever been reported to the Department of Children and Family Services for the neglect or abuse of any child, including Sara?

No, Sue responded.

Just because Emily was up front and honest with her clients didn’t lead her to believe they extended her the same courtesy. Even though parents knew she would eventually discover any history they might have had with DCFS, they would boldly lie right to her face.

Have any police reports been filed on any member of your family for allegations of child neglect or abuse?

No! Sue replied angrily, quickly tiring of Emily’s questions.

Sue, did you or Mark have any involvement whatsoever with the injuries Sara suffered tonight?

No! Sue shouted. Oh, God. I can’t believe this is happening! She had now begun to sob uncontrollably.

I know this is very hard for you. Although I need to speak with you further, I am going to stop for now. Someone from Children and Family Services, as well as a police officer, will be at the hospital later this evening. I just want you to be prepared for that. Sara is leaving the hospital now. I hope everything works out. Christian Children’s Hospital is one of the very best. They will do everything they can for her. Please let me know if you have any questions. Emily hung up after giving the mother the numbers where she could be reached.

Emily picked at a torn sticker on the front of the chart, her mind assessing the information she had just received.

Attempting to rub the tension that had settled into her neck and shoulders, Emily longed for the warm bed she left less than an hour ago. She pressed the speakerphone on her makeshift desk and asked the ward clerk if the investigating officer had responded to her call.

Nothing yet, Gina responded.

Thanks, Gina. Is it calming down out there any?

Yeah, but we all know how long that will last! I will buzz you as soon as the officer calls.

Emily closed her eyes and leaned back in her chair for a moment. Emily loved her job. Even all the tragedy she faced was often balanced out by the selfless acts and the empathy of the Scottsdale hospital staff. It felt good to be part of a team.

Emily’s thoughts were interrupted when Diane entered the break room. She pulled a seat up to the cluttered brown table centered in the room. Most of the test results and X-rays are back on the baby, Diane informed Emily. In the hospital, it was common for the patients to be referred to as The Baby, or even more often by their diagnosis, such as The Diabetic or The Broken Arm in Room Four. Emily had always believed that was the staff’s attempt to distance themselves from identifying too closely with their patients. If they let the problems of their patients affect them too greatly, they would never survive in this intense work environment. People often reminded Emily that she would benefit if she could develop a thicker skin and not get so closely involved.

The X-rays show signs of several old fractures; in fact, spiral fractures of both the left arm and the right leg. The CT scan also shows signs of cranial fractures. This kid has endured the worst. I’m sorry, Emily.

Has she left yet? Emily asked.

Yes, the chopper left about ten minutes ago. Did you talk to DCFS?

Yeah. Can you believe they gave me grief about coming out tonight? Emily’s irritation was apparent in her voice.

I’m sending the responding officer through on line two. Gina’s voice squawked from the speakerphone.

This is the ER crisis worker, Emily, she began, picking up line two.

Hi, I’m Grady Smith. I responded to a 798 earlier this evening. I was paged to call Scottsdale.

Emily worked with many of the police officers in the counties surrounding Scottsdale Memorial. Jackson was a small, close-knit community about fifteen miles outside of the city. Emily rarely worked with this particular department and had never before worked with this officer.

I’m calling to get some information in regard to Susan Germaine.

Yes, I’m the intake officer for that call. What can I do for you?

Did you do an initial interview with the baby’s mother and her boyfriend? Emily pulled out another social service report form to begin taking notes.

Well, they were both at the hospital with the child, and I spoke to them briefly, said the officer.

Did you interview them together or separately?

I just got some initial information from them, and I spoke with them both at the same time.

Are you aware the baby’s injuries are suspicious? Emily questioned.

Well, I know someone mentioned that the boyfriend had changed his story.

Emily was beginning to lose