Sketchy situation with MD and neonate

[6spdftwtm]

Hi all.

I am a travelor working in a remote location on part of the Navajo reservation. I have been an ER RN for over 5 yrs and "grew up" in a level 2 trauma center with 44 beds that rolled around 200-250 pts through per 24 hrs and WONDERFUL MD's who are all ER board certified. Here, the healthcare consists of the clinic and the attached 7-bed ER. The physicians are all supplied by a staffing agency (about half the RN's are agency). The turnover rate is high, but there are several MD's who continue coming back. One in particular is a new(er) MD and his residency was in pediatrics. Smart guy, knows what he's doing. I don't think he relies on his assessment skills and EVERYONE gets the million-dollar workup. Very much the "CYOA style". We have a lab that does most basic studies, x-ray (no CT scanner)...a crash cart, IV supplies, most emergency meds we'd need (except propofol....GO IHS!) We have chest tubes, central line kits, all the airway supplies (but no Glide-o-scope) There is no admission unit. All admits are transferred out. The point is that we can stabilize clients, but any extensive procedures or admission of any kind and they have to be flown out.

Either way, this is the situation:

2 month old male - fever 103.4 at home per parents (rectal temp), Tylenol given @ 1830 by parents. At 2000, in triage, temp 98.1R, HR 172, RR 44 unlabored, SpO2 100% RA. Neonate acts appropriate, interactive with parents and staff, no N/V/D, drinks fluids, producing adequate wet diapers, no rash, no cough, no runny nose....nothing except the fever, which parents report child has had "on and off for 2 or 3 days".

After IV with CBC,CMP (which were negative except a WBC 32.8). U/A cath ordered. Partially because infection control at this facility will not allow clean-catch bags and partially because MD requests caths on ALL uncircumcised males. 5Fr I&O cath attempted without success twice. Cath will advance just inside meatus and resistance met. After 2nd attempt, slight amount of bleeding. MD notified. MD is insisting on the necessity of a cath. Requests another nurse to attempt. At that point, after pulling the stopper out of 30cc syringe, capped luer lock, cleaning genital area well, and taping to clients perineum - ohh...and a 30mL fluid bolus, we have urine within 30 minutes.

Now comes the real kicker. MD, after learning of client's WBC count and while we are still waiting on urine specimen, is preparing to perform a SUPRAPUBIC URINE COLLECTION. Yes....we are going to stab a needle through the abdomen of this 2-month old BLINDLY and hope we hit that small little bladder. And if we miss bladder and something goes horribly wrong...well at least we can stabilize client (maybe) and transport to another facility. Secondly, MD is also voicing intentions of doing a spinal tap on client. Like...WOAH...this man has actually gone to the bedside and spoken with parents about these procedures and obtained verbal consent. I was beginning to really fear for this child's life. Not due to my doubt of the physician, but that we are so ill-prepared to deal with neonatal emergencies. These are both very risky procedures and the nearest NICU is 2 hrs by ground, 1 1/2 hrs by air and the nearest NICU that would actually accept this client, should something go horribly wrong, is 5-hrs by ground and 2 hrs by air.

So, at that point, I requested that MD please speak with transferring facility's pediatrician prior to doing these things. Or perhaps just allow transferring facility do these procedures if deemed necessary (it's a 1-2 hr transport time to closest facility). He agreed, however he already had the "Textbook of Pediatric Emergency Conditions" flipped open with "step 1,2,3" instructions on how to do the S/P urine collection.

What ultimately happened? Pediatrician at transferring hospital thanked MD here for offering to do these procedures, but his recommendation was to D/C IV and discharge client home and to follow-up in 24hrs, as this was likely simply a viral illness. Child F/U today with clinic and was discharged home with dx: viral illness.

I like the MD, he is polite and respectful of nurses, but I couldn't help to think that he was itching to do heart surgery in the bathroom.

What should I do? Reminder: this is a federal facility. IHS....federal government. And travelers opinions are not regarded very highly in response to complaints or suggestions about things that need to be changed.

Late,

Trav

[NicuGal, MSN, RN]

Where I work, that kid would have gotten a fever of unknown origin workup, no suprapubic tap...haven't done those in 20 years. Those WBC's might buy an LP, depending on the other symptoms or blood work, but with the WBC in the 30's the kid would have been a 48 hour rule out at least here.

With a 2 month old, they would go to peds, not NICU, neonates are defined as 30 days or less :)

[Altra, BSN, RN]

That WBC count would have been an admission where I work too, and I could definitely see an LP in the kiddo's immediate future.

[canoehead, BSN, RN]

We would have done the septic workup too, but not with the suprapubic tap. We'd just cath again after the LP, give him time to make some pee.