So there we were... trapped somewhere between Saturday and Sunday.
I imagine because it was about 2-o-clock in the morning and because both of us were still in casualty, it means that it was a standard Saturday night comserv call - attempted murder and mayhem, unidentified drunken injuries and the old faithful GBP's (generalised body pains which is code for end stage HIV and MDR TB because I stopped taking my ARV's again, 7 months ago).
If things had been semi manageable we would have split up for a bit of rest or supper.
But no - we were both there.
So this guy comes in with acute urinary retention and by the scar just above his pubic bone - this is not the first time his pipes have gotten blocked. I reckon after having a baby and allegedly a kidney stone - this has got to be the 3rd most unpleasantly painful condition - to have a litre of urine in your bladder and not be able to get rid of it.
He was not happy.
So we tried the conventional catheters - we tried the small ones, and the big ones, I tried and Dr S tried. No luck.
It was very obvious that the only way to get this beer byproduct out was to access it from the slightly less conventional route - trans abdominally.
Basically this involves shoving a trochar (medical jargon for a needle the size of a thin pinky finger) through your abdomen in the vicinity of your bladder to create a hole big enough to feed a catheter in.
We use a bit of local anesthetic - emphasis on 'a bit'.
Having done a few subsequent to this story I can now say that putting one in is a lot more benign than it sounds, but when you haven't been exposed to the machinery before, you are terrified. You see - abdomens do not only house bladders - they house a few other organs which do not take kindly to being pierced with big ass needles.
(In reality - if you're at the point of putting in a suprapubic the bladder should be the size of a small baby and in the way of most of these organs - but you never consider that when you're confronted with your first few.)
"Have you ever done a suprapubic?" I ask Dr S - confident that at some point in her 2 years of Baragwanath internship she must have done at least 1.
"No." was her slightly less confident answer.
Nervous laughter.
"Me either!"
So I'm thinking - 'Don't panic! I'm sure these suprapubic packs always come with instructions so...'
Dr S and I get our little trolley together - trying to think of pretty much everything we could need bearing in mind our poor patient is rocking and rolling on the bed in the casualty cubicle.
What was slightly disconcerting was that our instruction manual looked like it came out of a Christmas cracker...seriously it was about 3 x 5cm piece of paper with font 6 writing and no punctuation
"Ok, one of us must instruct and one of us must do...what do you want to do" I asked Dr S
She looked at me like I was asking the stupidest question in the world...
"Instruct."
Sometimes my calmness surprises me, and maybe at this stage of the year I had enough confidence to not care or my adrenal glands had burnt out. There may have been just a teeny tiny shadow freaking out inside of me though.
"Ok." Here goes nothing I think.
"Step 1: Clean the area..." fairly straightforward.
"Step 2: Inject local anesthetic over the area..." again - fairly straightforward. Patient not to happy about the 10mls of lignocaine that gets distributed between bladder and skin - but it's a lose lose situation for him.
"Step 3: With the scalpel make a 1cm incision approximately 1cm above pubic symphysis." Straight forward again.
"Step 4: Insert trochar..." Ok so this is where it stops being straightforward. There's this plastic sheath around the trochar that stays behind when you pull the trochar out to leave the hole that you just created open. Problem is, as you push the trochar deeper into the abdomen the plastic sheath slips down over the front of the trochar and well - it becomes a case of cutting flesh with plastic - in a word; ineffective.
Also - what you don't realize when you put a suprapubic catheter in for the first time is that there is actually quite a bit of tissue to get through before you hit a bladder. Of course you start freaking out half way thinking how can I not be in the bladder yet...surely I've missed it and I'm about to hit the aorta!
"Are you sure that's what it says Dr S?" I ask, seemingly making no headway while the patient writhes in agony - a combination of a full bladder and having minor awake surgery performed by 2 would be pediatricians. "Are you sure we didn't miss a step?" and that little freak-out voice is getting louder.
I take the trochar out, I make the incision deeper with the scalpel, I try again...not quite working...
"No I don't think we're doing anything wrong" Dr S encourages me meekly from the side..."Just keep going..."
So we continue to slowly push through the tissues - sometimes smoothly with sharp trochar, sometimes less smoothly with blunt plastic. Eventually there's a give and a veritable fountain of urine. Patient and Doctors are both covered in urine but very much relieved (no pun intended).
There's something awesome about getting these things right on your own... a little bit of a confidence boost for the next time you find an imminent breech delivery or a patient's heart stops beating in front of you.
Then there's the post-panic laughter that descends after the catheter's in and secured with a stitch, and the realization that this is not Greys Anatomy medicine which is supervised and sterile. This is South African medicine which is powered by camaraderie and Christmas cracker instruction leaflets.
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