02 April 2011

On Tap

For the first ninety days of Emmaline’s life I was coated in Purrel. For those of you who have seen my house, you know that I am a person who believes that a little dirt is good for you (at least that is what I tell myself to excuse the disarray). But for newborns, in the first three months of life, fevers bring with them a certain set of tests that I was determined to avoid.

A six week old is brought into the ER looking entirely well. She is smiling. She is nursing enthusiastically. When I first see her, she is bundled in his car seat looking fairly adorable. She cries only when taken out and stripped down to her onesie and even then consoles easily in her mother’s arms. But she has a fever of 100.4, the magic number, and so there are certain things we have to do.

The approach to febrile infants varies slightly from institution to institution, but generally speaking babies with fevers need to have testing of their blood, their urine, and their CSF. The first is done under certain circumstances up until six months of age, when the routine six month shots provide protection against pneumococcus, a particularly nasty bug. The urine is tested for good old fashioned UTIs and the cerebrospinal fluid testing is done to rule out meningitis.

 It all sounds fairly straightforward. It involves needles and catheters and holding down a screaming infant, but really this is all just part of a normal ER shift.

Until it doesn’t work.

The IV blows or the lumbar puncture (LP) is bloody. The urine can’t be obtained. Catheterizing a baby girl may be routine, but it is also sometimes impossible. Babies, especially the healthy ones, are incredibly strong and will fight when you are trying to stick things where they would rather you didn’t. The kids I really worry about are the ones who don’t. So she screams. She pulls her chubby thighs together. There is no way to get in. Sometimes it happens.

In the olden days, doctors would tap the bladder to get the urine, by which I mean stick a needle in the baby’s abdomen. Generally this procedure has fallen out of favor, what with involving a needle in the baby’s belly and all.

As an intern I was covering a patient who had a urine culture that indicated a likely infection. I called radiology to order the testing of the kidneys that was the standard follow up of a febrile UTI in that age group. The radiologist called back to demand I obtain a catheterized urine specimen since the sample catalogued in the computer was reportedly done by clean catch. The nurses had trouble with the catheterization, I explained. Then, when they cleaned the infant’s diaper area with betadyne before trying again, the girl had peed in a perfect arc into the collection tube. It was as clean a sample as we were going to get.

“Did you tap the bladder?” he demanded.

I told him that we did not. I had not been taught to, had never seen such a procedure performed, and didn’t think I deserved to be getting yelled at for things so out of the scope of my control, but such is life. He begrudgingly agreed to perform the testing and I went on about my day.

Should we tap the bladder if there is no other way to get the urine? Perhaps. Imagine an infant at that in between age, when doing the lumbar puncture is not absolutely indicated. If a source, such as the urine, is found to explain the fever, there are times when this other test can be avoided. So I asked a mother of one of my patients, would you rather have a needle in your baby’s abdomen or in the back? Which do you find more horrific? Which would you do anything to avoid?

“Stick the needle in her belly,” she told me.

Now this is certainly not a large enough sample size to make any real inferences. But it was not what I expected her to say. Maybe this is because I feel more comfortable with the prospect of performing an LP than a bladder tap, having been trained to do one but not the other. Still, I found it interesting. Bladder taps have not necessarily been cast aside because parents do not like them. The procedure brings with it certain risks. But I feel uncomfortable with the notion of them at least in part because I assume parents would object. It seems instead I should give parents more credit for appreciating that there are times you simply have to do what you have to do, whether it freaks you out or not.

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