(Trigger warning for discussion of coercive medical care, rape analogy)
I am loving my outpatient pediatrics rotation. Really loving it. Even when they are snotty, crying, and uncooperative. I love it. I am a little scared of how much I love it. I don’t think I would waver from ob/gyn but…it’s tempting, I’m not going to lie.
One thing that would make it difficult for me to be a pediatrician is the difficult concept of informed consent to care, and autonomy of the patient, when it involves a pediatric patient. (I am really into informed consent and right of refusal even for practitioners.) It can be complicated enough when we’re talking about adults who are patients. With minors, it’s even more complicated.
I know that pediatrics is in its own even grayer area, since many children, especially very young ones, would refuse all sorts of diagnostic tests and care if it was up to them. Most kids don’t want vaccines. Or blood draws. There are plenty of kids who scream and cry if you want to look in their ears. Pediatrics would look a lot different if children were allowed to refuse.
I saw a case recently that troubled me. My cousin Susan’s young daughter had symptoms of a urinary tract infection. (Details have been changed to protect privacy, as usual.) She had a fever and some sort of hesitancy or pain with urination that was hard for her to express because of her age. She also has a history of acute pyelonephritis with sepsis which required hospitalization, which is a pretty seriously complicated urinary tract infection (UTI). She was unable or unwilling to provide a urine sample. So, the practitioner decided to do a urinary catheterization so obtain a urine sample.
(Trigger warning here) It was a disturbing scene. It took two people to hold the screaming girl down, force open her legs, and the catheterization involved forcing an object into a structure in her vagina. She was whimpering and holding her vagina for a while after the procedure.
Sigh. I am not a medical professional yet. I fully understand why the medical practitioner wanted a urine sample to screen for bacteriuria. This practice is quite conscientious about not prescribing antibiotics when they aren’t necessary. Considering her history, she was definitely at risk for a complicated UTI. Waiting could have led to scarring of her kidneys, among other possible issues. Should she have been treated empirically? All of the antibiotics they could choose have side effects. A good clean catch from a catheter is ideal for a culture and sensitivity, for appropriate treatment. What if it was something else? Should they have sent her home with a urine collection bag taped to her? I don’t know. As I said, complicated. I was just disturbed by the fact she was offered a lollipop afterwards, as she sniffled and held her vagina. What kind of a message is this sending to this little girl? Does this, in some big picture way, contribute to acceptance of sexual assault, either by her in the future or by the witnesses?
Ugh. I am absolutely not questioning the ethics or the judgment of the practitioner in this case. It was obvious to me why she chose to catheterize the child. I am just saying I find it troubling, although justifiable.