HEMATURIA

It was a busy day in the E.R. It was already 1700 and I knew the rest of the shift would go by fast. My assignment was the unmonitored section. I looked to see that I got a new patient in one of my rooms. I quickly looked at the triage notes. The note read, “Hematuria (blood in urine) this morning. Now unable to urinate x 8 hours.” I looked at the age of my patient. It was a 63-year-old male. Suddenly I heard a yell along with profanity. It continued as the staff and patients looked over to bed 12. This was the bed my new patient was put in. I suddenly had the sick feeling I was not going to have a pleasant experience with my new patient. My gut feeling suggested I grab a Foley catheter kit. I also grabbed my clipboard and blank nurse’s notes and walked over to bed 12.

I walked around the curtain to see an obese elderly male. He appeared to be in a lot of discomfort. I set the Foley kit down on the counter.

“Hello. My name is…” as he stopped me in mid sentence.

“Why aren’t you damn people helping me? Can’t you see I am in a lot of damn pain! Damn it!!!” he yelled in a very loud voice.

At that time Joe the E.R. tech walked around the corner. My new patient Clyde began kicking his large legs in every direction. He almost kicked me standing off to his left side.

“I am going to get a Urojet and talk to one of the docs,” I told Joe. Joe remained in the room trying to calm him down. It did not work. Clyde continued to yell and kick. I knew he was uncomfortable and I wanted to get a Foley catheter in him as soon as possible.

I quickly walked back to the nurse’s station and talked with Dr. Wilson about our new loud patient. I told him I wanted to get a Foley in him as soon as possible. He agreed and wrote the order. I walked to the pxysis to get the Urojet and quickly went back to bed 12. The yelling from bed 12 continued. I thought about poor Joe. He already had a very bad day which obviously was going to get worse.

“Let’s put a Foley in,” I told Joe. He looked at me in relief. Clyde continued to kick his feet. I wondered if he was aiming at me because he almost kicked me again.

“You are going to have to watch your feet Mr. Jones,” I said.

“Screw you! Why aren’t you people helping me God damn it!!” he yelled loudly.

“We are going to help you Mr. Jones. I am going to put a catheter in your bladder to help relieve the pressure and pain you are feeling,” I said as nice as I could.

“Just do something, would you?” he yelled as he kicked his legs.

“You will need to stop kicking while I am putting down the catheter. It will go much faster if you were not kicking,” I said once again but in a firmer voice.

“Get the damn thing in me,” he yelled. 

I started to set up the Foley kit. Jim the charge nurse came around the curtain. Jim was a fairly large and in shape guy who was welcome in the bed 12 area anytime. He knew there was something terribly wrong. In fact, the whole city probably could hear Mr. Jones. Jim made sure the curtain was closed around the bed. I continued to set up the equipment.

Joe helped to get Mr. Jones’ pants down. I was getting the Foley ready to insert. It was a sterile procedure so I needed to maintain sterile technique. I put on my sterile gloves and started to set up my equipment. I had a certain order I did things. Mr. Jones continued to yell. Jim tried to reason with him but got the same response. I was getting a headache and knew I would take a short break after the experience with Clyde.

I was ready to insert the catheter. It was a #14Fr (French) catheter which was the standard size used. First I needed to put the gel from the Urojet in the urethra. I asked Joe to squirt the contents directly into the penis. Joe already had gloves on. The Urojet would numb the urethra to make the insertion more comfortable and tolerable for Clyde. Clyde continued to yell and kick his large legs. I grabbed the catheter with my right hand and Clyde’s penis with my left and inserted it down the urethra. Clyde continued to yell at me as I was inserting the catheter and tried to kick his legs. Joe was trying to keep Clyde’s legs and feet from hitting either one of us. I saw sweat coming from Joe’s forehead. Clyde was a large man and was strong. Jim helped hold down the legs. Clyde continued to yell loudly.

Once the catheter was inserted I inflated the balloon so it would remain in the bladder. There was red colored urine in the clear tubing. I also noticed several good sized clots. Clyde started to relax once the urine started to fill the plastic bag. The bag started to fill with red urine. I noticed there were a good amount of clots in the bag and in the tubing. The bag filled to about 500cc when it stopped. I knew Clyde had more urine in him because how distended his bladder felt and looked. I looked at Joe and Jim. I had a sick feeling it was clogged in the bladder from one of the clots.

“Could you get an irrigation set?” I asked Joe. He was out of the curtain before I finished my sentence. The poor guy was still sweating like crazy holding Clyde’s legs down. Joe returned in less than a couple of minutes and started to set up the sterile saline to be flushed into the catheter to hopefully dislodge the clot. Clyde was starting to get agitated again because his bladder was filling and he was uncomfortable. I did not blame him although I hoped he would not kick at me anymore. Joe started to flush the catheter. He flushed some of the sterile saline into the catheter and then pulled back on the syringe. There was red urine and blood clots. He flushed it several more times and then hooked the tubing back onto the catheter. The red urine began to flow once again.

Several minutes later the urine flow had again stopped. Clyde was spilling too many clots in the urine and it was clogging the catheter. It was decided to insert a larger catheter. Joe quickly went to the supply cart and got an 18Fr catheter. It was larger and should be able to handle the clots. Once again Clyde was getting agitated and started to kick his feet. He was not happy about the thought of getting another catheter inserted but he knew the one he had in would clot a lot. His profanity echoed through the E.D. I knew the patients and family members were wondering why I was torturing the poor man.

The catheter was inserted and the balloon was filled to secure it in the bladder. The red urine was seen flowing through the tubing into the bag. Clyde was beginning to get more relaxed and he stopped yelling and kicking. The urine bag continued to collect red urine with clots. It had collected 900cc when I left to go to the nurse’s station to chart. I also needed to check on my other three patients. Joe remained with Clyde to clean up the area and try to make him comfortable.

Fifteen minutes later I heard Clyde starting to yell. I walked over to Dr. Wilson and told him we inserted an 18Fr catheter and it was clotted again. I asked if we could try continuous bladder irrigation (CBI) to see if that would help the problem. He agreed and wrote the order. I went to where we kept the IV bags and grabbed a 3000cc bag of saline. These large bags of saline were used for CBI not for IV use. Then I went to the supply cart to get the CBI kit which was a three-way urinary catheter. It was to continuously flush the bladder to prevent the catheter from clotting and to hopefully get rid of some or most of the clots in the bladder. I walked back to bed 12 where Clyde was yelling.

Joe and I met each other in the bed 12 area. He heard Clyde yelling too and knew his catheter had clotted. He helped me hook up the CBI. The 3000cc bag of saline was spiked just like IV tubing but the tubing was much larger. The 3-way system allowed the saline to run into the bladder with one tube and exit the bladder into a bag from another. It was a continuous process to hopefully keep the catheter from clotting. Clyde continued to yell. I told him we were trying to take care of the problem by irrigating his bladder. He had some choice words for me. The system was attached to the catheter and the saline was running in wide open. I hoped it would take care of the problem and make Clyde happy. My head was starting to throb. I left bed 12 to look at my other three patients and chart.

The 3000cc was infused and there were quite a few blood clots seen in the bag. The urine was a lighter red which hopefully meant the bleeding had slowed down. The tubing where the saline was attached was clamped off and the draining bag was emptied. We hoped the clotting had slowed down and the catheter would drain without any more problems. Clyde was once again content and not yelling and kicking anymore. The E.D. continued to get busy.  

Thirty minutes later Clyde started to yell again. The catheter had probably clotted again. I walked over to where Dr. Wilson was sitting. I told him about the situation and the CBI only working temporarily. It was time to put one of the largest catheters down Clyde. Dr. Wilson was working on getting Clyde admitted to the hospital with hematuria of unknown origin. He suspected Clyde had bladder cancer based on his previous experience. He suggested putting in a 22Fr catheter. I walked back to the supply cart to get a 22Fr catheter. It was large and hopefully it would work. I walked to the pxysis to get another Urojet. Clyde would need numbing for this catheter to go down.  

One hour later after the 22Fr catheter was inserted Clyde’s urine continued to flow without problems. The catheter was large enough where the clots would not clog it off. Clyde’s urine was still red with numerous clots. The unit secretary gave me the bed Clyde would be admitted to. He was not happy about being admitted to the hospital but knew something was wrong and he needed help. Dr. Wilson talked with him at length telling him about the possibilities why he was bleeding. Clyde apologized to me for his behavior and the kicking and yelling. I told him I understood because I knew he was in a lot of pain and discomfort. I also knew Clyde would need to have more procedures to determine why he was bleeding and to rule out bladder cancer.

Joe was willing to take Clyde to his room after I gave report to the nurse. I told Jim I would be taking a few minutes off the unit. I walked to the break room to take a few minutes for myself. The E.D. continued to get busy. I could hear the patch phone in the distance as I walked around the corner.