Tuesday, April 24, 2012

Case # 5 - Late Night Urology Consult

A 65+ year old male with BPH had an abdominal surgery earlier that day.  After each of his last 3 surgeries he had developed urinary retention and went home with a Foley.  This time, he was sent home from the PACU without a Foley.  He presented to the ED with what looked like a soccer ball under his t-shirt.  He had not urinated since the operation.

Web 2.0 Resources used:
Foley attempts in our ED failed by a seasoned nurse, myself, the surgery intern, and finally by the chief surgery resident (who's service had done this guy's surgery and had pulled the intraoperative Foley).

The week before, I watched a lecture by the ultrasound director at UC Irvine, Dr. Christian Fox.  It was directed toward medical students, but I am a novice at ultrasonography, so it was perfect for me.  Dr. Fox said the bladder is like a box - so 3 dimensional measurements of W x Lx H will give you a pretty accurate reading.  He also told me that a bladder shouldn't hold much more than 1/2 L, so when I measured out 0.9 L, I was concerned.

I took out my Genius Scan app on my iPad, and snapped a picture of the bladder on the ultrasound screen, complete with measurements, and saved it to Evernote.

The patient was in pain, and he wouldn't take another Foley attempt unless it was by a urologist. Many of my co-interns dread making calls like this, but I was inspired. I had just listened to a very entertaining EM:RAP episode on testicular torsion given by Dr. Gary Tamkin and Dr. Mel Herbert.  They effectively remind us to be clear and unemotional with our consultants; tell them what you need. I sat down to page the urology consult at 2:50 AM.  As I picked up the phone I also pressed send on my iPad, and emailed the picture saved in Evernote to his email address.

"Are you seriously calling me to place a Foley?" he said.  "Tell surgery to do it."
- They already tried

"So get a senior to do it,"
- He already tried

"Why couldn't you get it in?"
- That's why I'm calling you.  I need you to tell me.

"Are you sure there's even urine in his bladder?
- Check your email

- Check your email; I sent you a picture of his bladder with 900 cc of urine in it

"It's 2 AM!"
- The dashboard says you are on call

"I am!"
- Oh, good, I'll see you in a few,
I overheard the urologist telling the patient something about how the 16Fr is his 7 iron. I think that's a good thing, but I'm not sure; I hate golf.  Either way, the patient got his Foley, and it returned about 890 cc of urine.  Only off by 10cc - not bad.