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An hour and a half into the process, I was getting a little tired of things. Three urology residents were bent over my patient with speculae and a headlamp, trying desperately to find her urethra.
Things had started to go badly when the fourth Foley catheter came out. (For those non-nurses in the audience, a Foley catheter is a long tube that goes into the bladder through the urethra and sits there, held in place with a little balloon filled with sterile water. It drains urine.) The damned thing actually shot out of her urethra and flew to the end of the bed, splattering urine as it went. I'd seen some interesting reactions to Foleys before, but never that.
I couldn't get the thing back in, primarily because I couldn't find her urethral meatus (opening). Normally, with women, this is not a problem--although bodies differ, I can usually manage on the first try. But this time? No go. No go, either, for the second-year resident, who found the ridge of muscle that usually marks the urethra, but whose attempts at inserting a Foley ended when the catheter coiled up time and time again.
So in came the third-year. He didn't have any better luck.
By this time, I had a lumbar drain that needed opening, so I went and did that. I came back to find the fourth-year in my patient's room as well, complete with OR headlamp and a variety of other...stuff.
No go. Still, with three people working away, sweating and cursing under their breath, no go. Things were complicated by the fact that my patient couldn't move her legs at all, and had some pretty amazing contractures.
Finally, the doctors figured out why they couldn't insert a catheter into this poor woman:
She had no urethra. And no neck to her bladder. They'd been worn away after twenty years of wearing an indwelling Foley catheter. The only thing left outside her bladder were three fistulas to the outside.
We put her in a diaper and scheduled her for a suprapubic catheter placement.
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Speaking of things you wish you could forget, I left a lumbar drain open too long the other week. Although my patient drained nearly double what she should've into the drain, her brain did not herniate down through her skull. I got very lucky, and so did she. There is no feeling worse than the feeling that you could've irrevocably fucked somebody up--unless it's the feeling of waiting to see if that's the case.
New nurses, take note: You will make minor mistakes on the average of once a day. Major mistakes might come as often as twice a month. A really huge mistake, like leaving a lumbar drain open for an hour, will happen at least once a year. The first time it happens, you'll be crushed. Later you'll learn to manage the mistake, figure out what caused you to make it, make changes in your practice, and keep going. Have faith.
And speaking of things new nurses should know, I have become a more-than-respectable IV starter. For the first three years, I sucked. There is no other way of putting it. Unless I was presented with a vein the size of a firehose on a comotose patient, I would dig and stick and fumble around and generally cause horrible bruises without getting a blood flash.
That seems to have changed, hopefully permanently. For some reason, over the last few months, I have had The Mojo. Even people with tiny threadlike veins that hide present only a minor challenge. I can't point to any one thing that changed in my technique; the only thing I can come up with is that the process finally got so routine that I was no longer spooked by it.
And finally, go read this. I tried to leave a comment, but was speechless. (The rest of her blog rocks too.)