The longer I do this job, the more misgivings I have about the traditional protocols for treating the febrile infant under 60 days of age. About the only reason I would consider doing an LP in the child described is because I don't have any data to defend myself if by some miracle, the child actually had meningitis. Is this a good reason to do an LP? No, but it is a practical reality, especially for those of us interested in practicing some semblance of evidence-based medicine.
Honestly, I probably would not do the LP in the scenario described because the child sounds like he is doing well clinically, the primary care physician seems to be following closely and good follow-up appears to be ensured. Of course, I would also send an RSV, viral panel and rapid influenza prior to an LP if I ended up deciding to do one. The presence or absence of close outpatient supervision would be a key factor in my decision to tap since I don't get the impression that the child was clinically worrisome other than the fever and infiltrate.
This position is, of course, relative heresy for someone who espouses discipleship to the Rochester Criteria specifically, and EBM in general. However, after having been away from the academic, teaching environment for almost two years now, I have found that there is merit in a certain degree of practicing according to how one *feels* about a given patient and clinical situation, pulling together not just the evidence about evaluation and treatment of conditions but also including one's clinical impressions and past experiences. Practicing EBM is the beginning of wisdom, not the entirety of it and while anecdotal medicine alone is malpractice waiting to happen, EBM alone is dogmatism run amok.
However, it is easier to defend ones actions with EBM, so the question becomes, how much do you believe in yourself? Can you get comfortable deviating from EBM when your gut tells you its overkill? Can you do this and still find a way to minimize and stratify risk? I don't have the answers...I just like to ask the questions.
R. David Smith, MD
Children's Acute Care
Cape Fear Valley Medical Center
Fayetteville, North Carolina
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