This subject has occupied me over time – my fascination with urinalysis – that is, the checking of urine for abnormalities; mostly whether bacteria are present (I’ve never found a urine virus, but it must be a thing, no?) Or, whether there are too many ketones, salts and so on.
I carry the picture of medieval monks tasting urine around with me as an image of dedication to the field.
Previously I have written about asymptomatic bacteruria – this is the presence of bacteria in the urine, often of older people, which are just there. Not harming anyone, merely present. All the evidence suggests that so long as there aren’t any symptoms, we shouldn’t do anything. Now, it is more complex than this I admit, but it is a thing and every-day causes confusion for nurses and doctors.
E.coli in urine > treat
Instead it should be
E.coli in urine > symptoms > treat
The image I have is one of Teddy Roosevelt rampaging across Africa in the 20’s shooting everything that moved; Lion! Zebra! Meerkat!
It is subtler, more nuanced than that.
The other aspect of urine is infections being blamed as a universal cause of all ills, again, in older people.
‘they fell’ – urine infection
‘confused’ – urine
‘chest pain’ – urine
‘diarrhoea’ – urine
You see the theme?
It is I suspect a human psychological trope where we like to apportion blame to the first thing we can think of; this reminds me of Brexit.
‘Unemployment’ – Europe (aka Europeans viz, Immigrants)
‘Traffic jam’ – Europe
‘Depressed/anxious’ – Europe
‘Wayward children’ – Europe
We love these heuristics, cognitive shortcuts that allow us to stop thinking and move-on.
So, urine isn’t a heuristic, blaming it for all ills is as simplistic as complaining about bad blood, nasty humours or sinister cerebrospinal fluid.
Now, why do I especially like negative urine?
When I say negative, I mean urine that has been analysed and found to be normal; just the right level of sugar, protein or salt; not too much or too little. Goldilocks pee.
What this allows us – the doctors and nurses trying to work out what is wrong with a person, to park causality; to exclude urine as the culprit.
‘their urine is a clean/dirty as my urine, it can’t be the cause of deterioration /dehydration /immobility’
Without this we are in the dark.
I would estimate that of my patients who are potential urine-misdiagnosis victims, up to half never have a urine sample sent to the lab or analysed; possibly more.
It is great if you find old person, symptoms, pee sample, lab result, directions to the appropriate antibiotics and off you go.
You see the complexity?
Rapid-fire thinking and actions do not lend themselves to this kind of behaviour.
Conversely, in hospital, everyone gets a blood test.
They are (for the most part) easy – arm, tourniquet, needle and voila.
Urine is harder to obtain. It sits deep within a pelvis, hidden in the bladder, down a urethra, surrounded by multiple potentially contaminating bacteria. How to get the pee?
I remember taking my daughter to the hospital when she was a baby; high fever and not sure of the cause. In babies they don’t mess around with hypotheses, they get samples even if it means stabbing the poor tots.
We dunked our little girl’s feel in warm water of the hospital sink and she peed.
We can’t do this with adults.
It is the inverse of taking a horse to water.
‘They are confused, we can’t get a sample,’ well, most ‘confused’* people are continent and can hold on to their water – even if on occasion, like everyone they have accidents and, asking for a sample (perhaps, after a cup of tea) is a way ahead.
If you can’t get a sample, you are faced with the dilemma of whether to accept defeat or try something else; this is often the situation if people are not with-it enough to comply. Do you just treat and hope for the best – contaminating other results with the presence of inappropriate antibiotics or, do you persevere?
This is the black-belt realm of medicine that is not at all straightforward and beyond the remit of this blog, suffice it to say, we have ways and means.
And, when I look on the computer and see that my patient’s urine is free of bugs or dodgy solutes I can be please, although this doesn’t make my job any easier – I am left trying to determine what is wrong and why.
Urine, I love urine, so long as it is not on my clothes and it is mine.
*Whatever ‘confused’ means.
For more on this subject, see here!