Since it was my first day as a real doctor, and my first day on call, I decided I should stop in to introduce myself (I subsequently discontinued this practice), and peeked my head in the door of her clean dark room. I explained who I was, and that I’d be on call overnight, if she had any kind of acute medical problems. I told her I’d read her chart and was familiar with her history. I had on my brand new white coat, which was so crispy that it made a distracting noise when I flexed my shoulder. It had my name embroidered in blue right above the pocket. I had some concerns that I had not turned my pager up loud enough and that perhaps I would not hear it if it went off. I remembered that I had not found out where the call rooms were, and wondered how I would go about finding them. I smiled warmly and asked her if there was anything I could do for her right now. She turned her swollen face away from the blue light of the TV and looked me right in the eye and said,
Fuck you.
I was somewhat taken aback. Certainly it is not the first time anyone ever told me such a thing; I’m quite used to it, in many ways. But I confess that it’s the first time I had heard it from a 13 year old patient. Why so crabby, I wondered, fingering my brand new reflex hammer, cool and reassuring in my pocket, scratching against several little spiral-bound books which would hopefully tell me what to do in case of any, you know, emergency. I was most assuredly hoping for the absence of any such event on my first night as an actual physician, and so had been disturbed during lunch to hear the Chief Resident explain the process for doing a lumbar puncture on a newborn in the middle of the night. A spinal tap on a newborn; I had somehow made it through medical school without ever successfully getting clear spinal fluid out of anybody, let alone a tiny baby. Blood, sure. Fat, bits of flesh, little hunks of bone, of course. But actual clear CSF? Not yet.
The perfect tap is supposed to be pure-sterile, devoid of even one single red blood cell. It’s called a “Champagne Tap,” both because it is sparkly clean, and because when you are the tapper of such a success, your supervisor is required by tradition to buy you a bottle of Champagne. Of course, most medical students and residents cannot afford even a little Moet, and so it ends up being just domestic sparkling wine, but it’s better than nothing. Lumbar puncture is not as easy as it sounds, at least not at first, and the first few I did were more like Merlot than Champagne.
There are actually many steps involved. The most pressing thing to do is to explain the process to the parents without unduly frightening them. Then you have to take their very cute, warm, cozy baby and lay him on his side on a table with nothing on but a diaper. Then the holder, usually a nurse, takes his arms and legs and draws him into an arc. You open up a sterile tray filled with a very long steel needle with which to puncture his back and a lot of clear plastic things to drain his oily spinal fluid into ( if you get any spinal fluid! Ha ha!) You put on gloves and a mask (mostly to absorb the sweat running off your forehead), and find a sweet spot between his vertebrae where you think the wellspring of liquor might reside. You take a scrubby swab of Betadine and draw ever-increasing circles on his back over your chosen hole-to-be, moving very slowly in hopes that someone will walk in the door and announce that the tap is not needed. When no one comes, and with his mother watching, you draw the stainless steel needle out of its opaque sleeve (no one likes to look at the bare bevel before it’s needed; it’s hooded like an executioner) and aim it at the soft little back.
The sensation of the needle piercing the epidermis is tiny, like the feet of a fly on the back of your hand, but instantaneously you encounter the tight ligaments; supraspinous, interspinous, ligamentum flavum. The resistance here is intimidating, but there is no where to go but forward. You increase the pressure, tentatively at first, and when nothing happens, a little more. Working your way through the fibrous barrier is the worst part, pushing, adjusting, angling; but finally the needle pops through the dura, a bizarre giving-way like cracking an egg that signals you wait for the fluid. You remove the stylet that occupies the interior of the needle, and if your aim was good, a tiny glistening drop of transparent liquid gathers at the hub of the needle. The surface tension causes the first drip to quiver at the edge, rolling off slowly as if it’s reluctant to leave.