A relaxing lunch with an emergency physician

I had lunch today with a friend who is an emergency physician. She congratulated me on the recent arrival of our son and said “Oh, don’t let anyone touch him for the first couple of months.”

Why not?

“If he gets a fever he needs to go to the ED and will get

  • stuck with a needle for blood and blood cultures
  • catheter urine specimen or needle into bladder (via suprapubic route)
  • lumbar puncture (what the lay public thinks of as a spinal tap) to rule out meningitis (newborns don’t have a well-developed blood-brain barrier yet)
  • IV antibiotics
  • +/- chest xray
  • hospitalization until results back (culture results take a couple days or so)”

Armed with a little knowledge, I feel much more relaxed now…

6 Comments

  1. Tom

    December 19, 2013 @ 4:32 am

    1

    I’d like to think she’s exaggerating a bit – if not then that’s genuinely scary! Here in Germany the medical system is expensive (#14 worldwide as proportion of GDP – fully 2/3 of USA level) and quite prepared to be interventionist (it’s not all spent on homeopathy and sanatoriums), but when our prematurely born infant daughter got a quite bad dose of RSV right at Xmas the hospital doctor (a teaching professor) spent a long while looking and listening, took a sputum sample for the lab but said that unless her condition deteriorated there was no need for active intervention and sent us all home with some palliatives.

    Now just as in the US they do like to make money, indeed if one has private insurance then it’s likely that the Oberarzt gets wheeled in for a second opinion at a higher charging multiplier, so why don’t the Germans indulge in a test-everything frenzy? I suspect it’s partly because the health sector is heavily regulated – the insurance companies compete on customer service and price but most of what they offer is mandated, meaning that there’s less opportunity for the doctor to add on endless extras, clipping the coins as he does so. And it’s surely a less litigious environment, so less just-in-case ass-covering. But what else – and more importantly what slippery slope would get Germany to the present state of the USA?

  2. Alexey

    December 19, 2013 @ 6:38 am

    2

    “He needs to go to the ED and will get”

    What’s the reason? Why torture a child right away? What’s the possibility of complications because of hospital stress and of being away from his mother?

  3. philg

    December 19, 2013 @ 9:23 am

    3

    Guys: I can’t tell you what the medical reason for this is. But she does seem to be accurately summarizing the standard practice in the U.S. I found

    http://www.childrensmercy.org/content/uploadedFiles/Clinical_Practice_Guidelines/Febrile_Infant/RSV/Full%20Sepsis%20Evaluation.pdf

    for example. The missing information here is likely that an infant getting a fever is pretty uncommon.

  4. Ed

    December 19, 2013 @ 10:01 am

    4

    One of my infants became febrile, convulsed, and was presented at an Irish emergency department. The tests weren’t nearly as invasive as what is described here, and he was home in hours, with instructions to keep his temperature a little lower – and that was it.

    Somebody is under-testing or over-testing here; overall Irish mortality rates for small children are better than in the US, but I don’t have a break-down specific to cases where meningitis is suspected.

  5. lv

    December 20, 2013 @ 12:21 pm

    5

    Congratulations on your new son! I am expecting one in February so your first post was exciting and touching to read, and this one (one day after baby-safety course which I thought comforted me) got me “much more relaxed” too.

    Seems like this is standard procedure for 0-28 days and similar for 28-60 days: For example Bacterial meningitis is more common in the first month of life than at any other time.
    http://emedicine.medscape.com/article/1834870-overview#aw2aab6b2b2
    Neonates with fever who are aged 28 days or younger may have few clues on history and physical examination to guide therapy. Therefore, a high index of suspicion is necessary in order to detect the febrile neonate with a serious bacterial infection.

    I assume in some cases they can rule out bacterial infections and treat more lightly, some studies:
    http://www.uptodate.com/contents/strategies-for-the-evaluation-of-fever-in-neonates-and-infants-less-than-three-months-of-age?source=see_link

  6. Aaron

    December 23, 2013 @ 4:06 pm

    6

    They don’t mess around with fevers < 1-2 months because there is so little margin in a newborn. No, it's not pleasant, but it is what it is.

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