John Monaco, M.D.
Admitting sick children to the hospital is almost always as traumatic for families as it is for the children themselves. This is not true just for those who are severely ill or victims of trauma. I have come to realize after many years of caring for kids in hospitals, that the degree of the child's illness is not always proportional to the level of anxiety experienced by families. There are families that handle any hospitalization well and then there are those who handle even the simplest things with great difficulty. It is the challenge for the health care provider to understand this phenomenon and not prejudge what the family's reaction will be based on the degree of illness of the child. I was reminded of this not long ago when we admitted a six week-old infant with unexplained fever.
It is well accepted in pediatrics that children under six or eight weeks of age who have fever fall into a special category. Basically, they are considered to be an "immune-compromised host," which means they are more likely to become infected because their immune systems have not yet developed fully. Also, because of their recent birthing experience, they were exposed to bacteria and viruses that can be deadly if they invade and cause infection.
If a source or explanation for the fever in a child under two months of age can be found, like an ear infection or urinary tract infection, this can be treated simply and effectively in most cases. The decision to hospitalize a child with either of these, or some other easily recognized source for fever, depends on the degree of illness of the child.
If, however, no source of infection is discovered by either physical exam or initial laboratory tests, then these children are assumed to be "septic" until proven otherwise. Sepsis is a clinical state characterized by a spectrum of physical findings felt to be the result of an overwhelming bacterial infection. As we mentioned, newborns are particularly susceptible to overwhelming bacterial infections. Therefore, if sepsis is at all suspected, they are treated as if they have such an infection until it can be proven that they do not. This means that they must be admitted to the hospital where cultures must be taken of blood, urine and spinal fluid. Antibiotics are begun and continued until all cultures are found to be negative indicating that the child does not have a bacterial infection.
Our six-week-old little girl was in such a category, and as such, the aforementioned cultures would have to be obtained. Notice that when I mentioned cultures are needed for this work-up, I included spinal fluid, or CSF. To obtain this particular sample, a spinal tap, or lumber puncture is required. The specter of this procedure raises tremendous anxiety in parents. Without question, it is a very scary procedure. It involves a needle inserted into the lower back, between the spinous processes of the vertebral column, and extraction of cerebrospinal fluid which is sent to be analyzed by the lab for evidence of infection. The procedure itself is performed under sterile conditions, with local anesthesia and sometimes conscious sedation. The spinal tap or "lumbar puncture" is actually a fairly common pediatric procedure performed hundreds of times a day by pediatricians everywhere; yet because of the sound of the words, or images created by TV and the movies, it sounds frightening and intimidating. The complications rate is extremely small, and when complications do occur, they are most likely done at the hands of practitioners who are not trained or experienced in performing pediatric procedures.
None of this, of course, matters to the anxious parent of a baby that has only been home for a few weeks and who is about to experience a needle in the back. The parents of this little girl were no different. Unfortunately, the ER physician was unable to convince the family that the spinal tap was indicated, so the family was unwilling to sign the consent for the procedure. Without the consent, the procedure could not be done.
Fortunately, our pediatric intensive care unit nurses and I were more successful convincing the family that the procedure was necessary and safe, so it was left to us to do the spinal tap once the child arrived on the pediatric ward. I spent a long time talking to the mother, who was alone when I entered the patient room. After a lengthy discussion which began to feel like a sales pitch by me, the mother agreed that I could perform the tap. Unfortunately, the father was not there at the time the discussion took place. He arrived just as I was about to perform the procedure and had already taken the child into our little procedure room on the ward. His arrival was something I will not soon forget.
I was standing in the procedure room; the nurses had already brought the baby in and were positioning her for the spinal tap. I was scrubbing my hands with my back to the door and to everyone in the room. When I turned, the doorway was darkened by a very large man. He had an expression that could be described as both frightened and at the same time frightening. I, of course, was surprised to see him there, but assumed right away that he was the father of the child I was about to tap.
"You better not let anything happen to my baby!" was the very first thing he said to me.
"Sir, that is not my intention at all." I tried to remain cool. "Have you had a chance to speak to your wife?" I tried very hard to pass the pressure on to the family.
"Yeah, I talked to her," he said with an uncomfortable degree of swagger. "And that's why I'm here. She says you are going to stick a needle in my baby's back, and I'm not sure if I'm OK with that." He literally sneered at me.
Surprisingly, I kept my cool. Although there was a moment when I actually thought that he might take a swing at me, or at least grab me by the collar and shove me against the wall, I kept talking to try to dissuade him from such extreme action. Thankfully, I was successful but by the time he left I was shaking, and the nurses weren't sure if I was going to compose myself enough to be able to perform the procedure.
In the end, I did perform the procedure. The baby tolerated it quite well, and thankfully, she was proven not to have meningitis. The mother was extremely relieved when I returned the baby to the treatment room intact, and the father was silent. By the time the child was discharged, the father was actually able to thank me, and to apologize for his outburst in the treatment room. I told him that no apology was required. I knew how stressful any pediatric admission could be, and his reaction was entirely justified. He smiled and thanked me, and I breathed a sigh of relief that his initial anger had not gotten the best of him.
John E. Monaco, M.D., is board certified in both Pediatrics and Pediatric Critical Care. He lives and works in Tampa, Florida. He welcomes your comments, suggestions, and thoughts on his observations.
May not be reproduced in any format without written permission.
