Page 1 of 3
“Aaahchoo! Ugh, please excuse me.” You simultaneously introduce
yourself while sanitizing your hands after what feels like the 100th
sneeze of the day. Most of your patients that morning have been very
sympathetic to your congested and less-than-peppy state, and you’ve even
received a few shameful apologies from patients who note that they
shouldn’t be in the emergency department if they look and feel better
than their doctor. It’s been a rather rough “Flu Season” and the coughs
and sniffles aren’t going out of style any time soon. The parents of
your next patient seem to be sporting the season’s latest drippy nose
and laryngitis combo, too.
“Hi doctor. Will you please tell my wife that our baby does not need antibiotics again?” You put on your best mediator smile and ask, “What seems to be going on with your little princess today?” Dad thinks their 6-month-old daughter has simply caught one of the viral infections that has been going around, as both parents and two of her older siblings are also sick. She’s had a fever up to 101.5 for the past few days, but has been eating and drinking at her baseline. Other than an intermittent dry cough, clear rhinorrhea, and being a bit more fussy than usual, the patient has been doing just fine. Mom had taken her earlier this morning to one of those “Doc-In-A-Box” clinics that opened up near the local Wal-Mart, and was surprised when they diagnosed the baby with a urinary tract infection. She told the Dad about her concerns, and now they’re here before you seeking your words of wisdom / second opinion. Mom hands you a copy of the normal chest X-ray results, doctor’s discharge instructions, and the antibiotic prescription from their earlier evaluation. You notice that they had “bagged” the baby for the urine specimen, and that the urine was contaminated by a large number of squamous cells.
Dad explains that the baby has been put on antibiotics three times this past winter for “bladder infections” and he’s not too keen on doing it again. You are halfway through explaining how you would like to catheterize the baby for a better urine specimen when Mom interjects and tells you “It’s impossible”. On further evaluation, you discover that the baby has had problems with labial adhesions and her overzealous antibiotic-loving doctors have been treating her based on “bagged” specimens because catheterization has never been successful. She may have had a “true” urinary tract infection when she was younger, but the parents don’t recall the specifics, and they haven’t been able to afford any follow-up other than sporadic visits to local clinics.
You don’t want to miss a urinary tract infection in a young patient who has significant risk factors, but you’re not about to go along with the other practitioner’s plan to “empirically treat” a contaminated urine, at least not without a fight. You have an idea. Thank goodness you’ve been working on your ultrasound skills! You explain that there is a third way to obtain urine, and even though it sounds scary, it is just as safe as the other ways. You then obtain consent to perform a suprapubic bladder aspiration, and go gather your trusty ultrasound machine and supplies. With the ultrasound probe resting gently across the suprapubic region, you obtain the image depicted in Figure 1 showing a full bladder. After you prep the patient and transducer in a sterile fashion, you capture the following image during your aspiration attempt (Figure 2).
What do you see in the above images?