What to Expect When you Arrive at an Emergency Room with Your Baby
by Audrey Paul, MD, PhD, FACEP , Karen Goodman, MD, and Catherine Verow, MS, CCLS
1. Triage
Certain patients require more immediate treatment than others. In order to help ER staff prioritize, triage is the first stop for all new patients in the ER. At triage, a nurse will perform a preliminary physical examination. The baby’s weight, heart rate, temperature, oxygen level and, sometimes, blood pressure will be measured. If you have a copy of your newborn emergency card, now is the time to share it. The parent or caregiver bringing the child to the ER will be asked the baby’s medical history, including birth history, and the reason why the baby was brought to the ER.
Important Tip: If, after answering these questions, you feel the triage nurse is missing certain information, tell him or her. More information is better than less.
2. Evaluation by a Physician or Nurse Practitioner
After triage, you and your baby will be directed to a waiting room or taken directly to a treating room to be seen by a physician.
Important Tip: Since newborns are particularly susceptible to infection, you should ask to be placed in a more isolated area or, if available, a private room.
Next, a physician, nurse practitioner or physician’s assistant will see your baby. Your baby’s medical history will be reviewed and additional questions may be asked. This will be followed by a physical examination. The health professional conducting the exam, may consult with one or more colleagues. If necessary, the treating physician may request that one or more sub-specialists examine your baby and make recommendations about care.
Important Tip: If you think your baby’s condition may require a particular specialist, don’t hesitate to inquire whether that physician is on staff and is available – either “in house” or “on-call.” Learn more about all the pediatric subspecialities from the American Academy of Pediatrics.
3. Testing
If your baby is less than 60 days old and has a fever of 100.4 or higher or exhibits other physical symptoms, a series of important tests known as “rule out sepsis” or “fever work up,” will be done. In order to rule out or identify infection, physicians will need to draw samples from your baby for labwork, and conduct tests including:
- urine tests
- blood tests
- spinal fluid tests
- additional screenings commonly include a mucus swab, EKG, or X-ray
For the urine test, the area in which your baby urinates is cleaned. A catheter (a tiny flexible plastic tube) is used to collect urine. The tube is coated with Vaseline to make the procedure more comfortable. A quick urine “dip” test assesses whether there are signs of infection. The urine is also sent out to be cultured, to see if any bacteria grow over time. Culture results usually come back after one to two days.
Blood, like urine, is sent for a rapid tests to look for clues of infection. Blood cultures are also sent out, to see if bacteria grow. Like a urine culture, blood culture results usually take one to two days. More rapid tests like a “CBC” gives doctors information about a baby’s white blood cell count. White blood cells are the cells that fight infection and may be elevated in babies when they have infections.
In order to test for serious infections that may spread to the brain, a spinal tap is performed.
Important Tip: If it is not offered, you should ask for numbing cream to be applied to your baby’s back before the spinal tap is done.
During this test, your baby may be held in a flexed position (knees to chest) on his/her side or sitting up. A small spinal needle is placed in the lower back between the back bones. Spinal fluid is collected and sent to the lab for rapid tests that come back in 1-2 hours, as well as cultures which take one to two days to grow. Rapid tests can help determine whether your baby has a bacterial or viral infection. Some centers can run additional viral studies to determine if the cause of your baby’s infection is viral. Depending on your baby’s symptoms, the doctor may order additional tests like a chest x-ray to look at your baby’s lungs or an electrocardiogram (“EKG”) to look at your baby’s heart. Depending on the season, a doctor may collect mucus from your baby’s nose to test for viruses like flu or RSV.
Important Tip: While your infant is being examined, if at all possible, hold your baby. Holding your child not only promotes close physical contact, it gives you an active role in supporting your child in a positive way. Holding and cradling your baby in your arms can help make her/him feel safe, thereby reducing stress and anxiety. Also, speaking in soft tones to your baby and singing can be comforting for both of you.
4. Treatment
After the tests are completed, your baby may be given antibiotics through an intravenous line. Sometimes antibiotics may be given before the tests are done.
5. Admission
A baby less than 28 days old, who has a fever, will be admitted to the hospital for further observation and treatment. This is the standard of care at all hospitals. Antibiotics will be continued until all the culture results come back. Parents are always encouraged to stay with their baby, who will be placed in a crib.
Babies may be hospitalized on a general pediatric floor, or a floor with closer monitoring like an intensive care unit or a neonatal unit.
Important Tip: If your baby is not admitted, make sure you understand why and what the discharge instructions are. You can always ask more questions if you are unclear or feel uneasy about anything that has been discussed. If you do not feel comfortable taking your baby home, you may request that your baby receive further observation either in the ER or by admitting the baby to the hospital.
Don’t hesitate to ask any question, or ask for more information if you feel you do not understand what the doctor is telling you. While there are general standards of care, not everything is set in stone. Physicians can and do exercise their judgement. You and your doctor should come to an agreeable, comfortable plan together. Remember that you are your baby’s best advocate!
Conclusion: If your baby exhibits any changes or symptoms that appear severe or life threatening, go to the closest ER immediately. If your newborn does not have a fever, and does not appear to be in immediate distress, but something still does not feel right to you, trust your instincts! Call your pediatrician. An ER visit may or may not be necessary, or your pediatrician may recommend that you go to a pediatric ER. When speaking to your pediatrician, ask if your ER is staffed with pediatric emergency medicine physicians 24/7, since pediatric emergency physicians are often more comfortable managing pediatric emergencies especially in newborns.
Ultimately, you are your baby’s best advocate, and you know your baby best. If you have any questions trust your instincts and always call your pediatrician. In an emergency, if you do go directly to the ER, you should contact your pediatrician. Your pediatrician can be helpful not only medically (by providing information to the hospital staff) but also emotionally. Your doctor knows you and your baby and can help you deal with a stressful situation.
Remember, newborns show symptoms and signs of illness differently than older children, so staying attuned of and being aware of the best expertise and being prepared for the places to go for any potential newborn emergency can be life saving!