Please Cath Me!

I want you to reminisce to when you were 21. Remember those days? The good years. When nothing ached. When the bills weren't big. When your biggest decisions were what to wear, how to fix your hair, and who to go out with.

When you could pee without a struggle.

Now, hold on, don't assume this is about me. It's not. I'm way, way too young to worry about that problem just yet (I think I just heard my wife laughing).

This is about my next patient, a local 21 year-old college student.

I live in a town where we have four colleges. Really great, fantastic schools. As a result, though, a portion of our ER patient population are college kids not from this area. Anonymous kids who aren't afraid to come see us so we can cure their "drip" or "discharge." Well, at least until the next time. But, all in all, good normal kids.

So, imagine my surprise when a nurse walked into the nurses' station and asked me to urgently see her new patient. A man who couldn't urinate. A 21 year-old man who couldn't urinate. Now, we're used to the older male patients who can't urinate, but 21?

"Are you kidding me?" I asked, waiting for her to say "Gotcha."

"I wish," she answered, all business-like, "and he's really uncomfortable."

Well, at 21, there isn't much to hold the flow back. A UTI. An STD. A kidney stone. Trauma. Neurological disease. Medications. Crazy. I ran through my internal list as I approached his room.

I walked into the room to find a young man writhing in his cot. "Please cath me!" he exclaimed before I could even introduce myself. Now, this was a first for me. Go back to when you were 21 again and tell me if you knew what catheterizing even was (heck, I'm not sure I could have even spelled it!). How did this kid? And what was his story?

It turns out this was a heck of a nice kid who had this happen to him once before. He had a phobia about airplane bathrooms and urinating at 15,000 feet. He was on a return flight, after a visit to home, when he felt the urge to urinate, just as Murphy's Laws would dictate. Thinking ahead, he believed he would have enough time to relieve himself in the terminal once he landed and before catching his connecting flight. Wrong!

His airplane didn't land in time, instead circling in the air waiting for its clearance. This poor kid's kidneys didn't know this, though. They kept filtering his blood and dripping more and more urine through their connecting tubes into his bladder. A dripping faucet filling up the clogged sink. Drip. Drip. Drip. By the time the kid had landed an hour later, he was in misery.

With only five minutes to catch his connecting flight, he hobbled through the airport, passing several bathrooms. Can you imagine making such a decision? Should he keep running to make his connection or should he stop to urinate, miss his flight, and then sit around and wait for the next unknown connecting flight?

He opted to catch his connecting flight. He told me he spent half of the hour flight in the airplane bathroom trying to go, ignoring all the knocks. He was obviously unsuccessful. Even without a phobia, I wouldn't be able to relieve myself with someone knocking on the door, either. Ducking down from the low ceiling, rocking back and forth from turbulence, staring down at that ridiculous metal basin they call a toilet, and then multiple knocks on the door? Sorry, bud, no can do. They need to get some Depends dispensers!

An hour and a half later, he was my patient. I ran and got our portable bedside ultrasound and hurriedly placed its probe on this kid's belly. Sure enough, he had a bladder big enough to fill a backyard pool. Eight-feet deep, no less!

The bladder is a tricky organ. Once it is stretched enough from filling with urine, the nerve fibers convey to your brain the need to find the nearest bathroom, do not pass go, and relieve yourself. In this kid's case, though, his bladder continued to fill beyond its capabilities to contract. Thus, he had a bladder screaming at him but no longer able to squeeze out the urine. An "atonic bladder" for those of you hoping to answer the final question on Jeopardy someday. This can be quite an uncomfortable predicament. A catheter was his only answer.

The nurse, relishing her role as a patient advocate, hip-checked me out of the way the second I was done with my ultrasound. She had a catheter in her hand and she was ready to save another life (her second one that day if you count the dental pain patient she and I had treated earlier!).

Unfortunately, the nurse was unsuccessful in passing the "too-big" catheter into his bladder.

"Hey, Doctor K," she yelled loud enough for three rooms over to hear, "can you grab me the smallest catheter in the med closet or, better yet, a pediatric one?"

Say what? Are you kidding me? He's 21, for God's sake, don't insult his manhood this way! Where are all the understanding male nurses when you need one? I made a mental to tell the nurse that if I ever needed anything less than a garden hose for a catheter, she better not yell it out to the other rooms, thank you. If I'm being honest, though, if I do need a garden hose, I would be okay with her letting the whole ER know (that better not be my wife I hear laughing again!).

The nurse was successful in placing the smaller pediatric catheter in this patient and immediately, almost one liter of urine drained out. Before he was discharged, he had drained two liters of urine. Can you imagine? Two liters! I am not embellishing here, we have markers on the collecting bag. And let me tell you, the day I can fill a two-liter Coke bottle in one squirt is the day I'll win a pissing--oops, I mean bragging--contest!

The patient did awesome. As soon as the urine started flowing out, he was a different person. We tested him for a UTI, a kidney stone, and STDs and he passed with flying colors. That's my boy! We offered to let him wear the catheter home with a draining bag attached to his leg, but he refused.

"What, are you kidding me? You mean wear this thing to class tomorrow?" he asked incredulously. I understood completely. I could only imagine what a chick-magnet a catheter with a leg-bag would be in college. Picture it--biology class. Pretty girl on his left, speaking to him. "Excuse me, but is it me or does it smell like a nursing home in here?" A pause and then she'd continue. "And why is your left thigh so much bigger than your right?"

When he left, without his catheter, he couldn't have been more appreciative...and comfortable...and homesick.

"Please cath me!"

Yeah, right--I'll take quotes you'll never hear a 21 year-old say for $200, Alex.

As always, a big thank you for reading. Next post will be Wednesday, January 27. A shout-out to all of you who have blogrolled me, twittered me forward, and have left cool insightful comments. And to those who have nominated and are supporting me for the 2009 Medical Webblog Awards at MedGadget.com, I thank you. I am very humbled...

Not A Hussie

The way our ER is designed, one of the patient treatment rooms, Room 15, sits directly across from a physician work station, a place where we can sit to do our charting, catch up on computer work, use a telephone, and review computerized radiographs.

We have several similar stations throughout the ER, but this one is unique because of the direct view it shares with Room 15. Despite our best efforts to keep the curtain drawn and the sliding glass door closed to this room, there are many moments when a patient and their family can "people-watch" us in the midst of a shift. I actually feel like someone might toss me some peanuts if I clap my hands and dance for them.

It works the other way, too. A screaming dementia patient can ebb away at your last thread of sanity in the middle of a crazy shift. The smell from a patient with a lower GI bleed can give you dry heaves, and the lingering apple-scented spray used to cover the smell only makes things worse. Even the conversations that are overheard, from critiques of the physical characteristics of our nursing and physician staff to the sharing of in-depth personal confessions and secrets, are enough to make one wish for an instant cement-block wall. Graffiti optional.

During one recent shift, because of the noise emanating from Room 15, I was quite happy not to be sitting at this particular station. One of my partners was, however, and I needed to talk to him.

As I walked down the hallway towards the station, the screaming and ruckus only intensified. I found the physician and connecting nursing station bare of any warm bodies and suddenly, I was worried about the happenings in Room 15.

I walked quickly into the room to see if I could be of any help. What I found was one of our recently-hired graduate nurses, Michelle, at the bedside of an elderly woman who obviously suffered from dementia. The patient was aimlessly yelling and aggressively trying to climb out of her bed. Michelle was struggling to get the patient back into her cot and despite her best efforts, this 100 lb. frail little lady was succeeding and now standing at the foot of her bed, all in the blink of an eye.

"Michelle," I asked, walking to the patient's other side as I spoke, "where is everybody? What can I do to help?"

"I think the patient in Room 18 crumped and everybody ran in to help" she answered. "Can you help me get Mrs. K. back into her bed?"

"Of course," I said, thinking this would probably be the easiest thing I would be asked to do during this shift.

Together, we tried to coax Mrs. K. back into her cot. Unsuccessfully. Mrs. K. had other ideas, I suspect, of taking a self-tour of our ER. It seems for every step back we convinced her to take, she took two forward. And she was a strong woman! Why does it seem that the more frail a patient appears, the bigger their can of whoop-ass? She was whooping us, no doubt about it. Heck, I thought, she wasn't even my patient!

Finally, I had had enough. Michelle and I were simply not going to win this battle. I work out often and although this woman's spirit was big, she did just weigh 100 lbs. So with that, I bent over, scooped up Mrs. K. in my arms, and easily placed her back in her bed. Problem solved. In fact, I suspect Mrs. K. enjoyed the ride. As soon as we got her back in bed, fluffed her pillow, and covered her with a warm blanket, she started napping, her outburst a thing of the past.

Guess what, though? After I picked up Mrs. K., I found my right arm, the arm I used to scoop her up, soaking wet.

"Michelle," I asked, "what do you think this is from?"

"Ughh, gross," she said, staring at my drenched arm. "Maybe she had an accident."

Do you think? I looked at my arm and my mind went rampant imagining what the wet was from. The best I could hope for was that it was something yellow. You gotta love Mrs. K. She showed me who was boss after all.

I went to our sink and scrubbed my arms with disinfectant soap. Twice. Three times. When I was done, I smothered myself in antimicrobial gel. That should take care of the juicing I just received.

Wrong. Soon after I returned back to my patients, I discovered a rash starting on my right arm. Only my right. The one that had the wet stuff on it. I looked at it and wondered, as you would, what the hell???

It was definitely a urticaric rash, better known as hives. What could Mrs. K. possibly have given me? Had she been a promiscuous hussie in her youth? Did her urine contain uranium? Was I allergic to recycled apple juice? I was cursing myself for being a good Samaritan. Was getting a rash on my arm worth this?

Of course it was. I would have helped Mrs. K. and Michelle again in an instant.

I went and washed my arms again. Twice. Three times. Then I took 50 mg of Benadryl and changed into a long-sleeved shirt.

I obsessively kept checking my arms. And after about fifteen minutes, I noticed something that made me feel a lot better. Made me smile, actually.

My left arm was getting a rash on it, too.

Why would I possibly be happy to be getting the rash on my left arm, too? Easy. If the rash were only on my right arm, then that unknown wet stuff would have been the source. But...if both of my arms were afflicted with the rash, then it obviously had to be from either the soap or antimicrobial gel I used. My left arm never had anything wet on it.

Washing my arms six times and smothering them with gel twice had gotten to me. Mrs. K., thankfully, had nothing to do with my affliction after all. And sure enough, after about an hour, the rash started going away. On both arms. Shame be gone.

Mrs. K., I owe you an apology. I didn't really think you were a promiscuous hussie in your youth. I promise. In fact, I really enjoyed meeting you as you reminded me of my grandmother. And wherever you are, I hope you are well and still showing the world your indomitable spirit!

Just not in Room 15.

As always, thanks for reading. Next post will be Monday, January 11th. Have a great weekend.