forced catheterization

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cbmedic

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Two nights ago, a drunk/intoxicated patient was brought into the ER. He was violent, and security put him into four point restraints. His clothes were cut off. I was one of the attending RN's, and I was ordered to catheterize him. I refused. I said I would not cath him unless he was sedated, to spare him any pain or humiliation. I was told that the MD would not introduce any drugs into his system until urinalysis results came in.

What would you have done in this situation?
 

Veneficus

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Two nights ago, a drunk/intoxicated patient was brought into the ER. He was violent, and security put him into four point restraints. His clothes were cut off. I was one of the attending RN's, and I was ordered to catheterize him. I refused. I said I would not cath him unless he was sedated, to spare him any pain or humiliation. I was told that the MD would not introduce any drugs into his system until urinalysis results came in.

What would you have done in this situation?

Cath him. That's what we always do.

We don't drug suspected tox patients until the urine sample.

If you make his tox screen positive, you mask organic evidence of altered mental status.
 

VFlutter

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I would absolutely cath him. And honestly I have had a Foley before and they are not that bad, uncomfortable but not really painful. Would it be less "embarrassing" for him to urinate all over himself and cause potential skin breakdown?

When do we ever sedate or provide analgesia for Foley catheters? Have you ever done one? Its clean, lubricate, insert. That is it. I put multiple caths in a shift on patients who are completely A&O, non sedated, non pain meds on board, etc and I have never felt like it was even remotely needed. He is already intoxicated what more do you want?
 
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Linuss

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Cathed. The medical benefit outweighs the temporary pain. Do you sedate people before an IV? I don't.



Having said that, I've made it quite known that I will not go down without fighting when someone tries to cath me while conscious. That's for exit only as far as I'm concerned!
 

NYMedic828

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I would absolutely cath him. And honestly I have had a Foley before and they are not that bad, uncomfortable but not really painful. Would it be less "embarrassing" for him to urinate all over himself and cause potential skin breakdown?

When do we ever sedate or provide analgesia for Foley catheters? Its clean, lubricate, insert. That is it. I put multiple caths in a day on patients who are completely A&O, non sedated, non pain meds on board, etc and I have never felt like it was even remotely needed. He is already intoxicated what more do you want?

Having had one for surgery before, the worst part is when they take it out...

Felt like I had to urinate 24/7 for 2 days.
 

Aidey

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Don't most hospitals also have lidocaine lube for foley insertions?
 

Veneficus

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Don't most hospitals also have lidocaine lube for foley insertions?

If that is what comes in the kit.

I never read the package before. Reading the fine print after setting up a sterile field and gloving up was never on my "to do" list.
 

firetender

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Just wondering...

I can't imagine you having gone through RN training and not seeing that catheterization is relatively harmless and painless to the patient. No more so than an IV, though I definitely have the same personal opinion as linuss!

I'm wondering if you thought the order for catheterization was to punish the pt.

I'm wondering how your refusal to follow up on a Drs. orders turned out for you.

I'm wondering if you felt you could get an adequate urine sample from a combative patient in restraints. Did you thing you could?

Guess I'm just a wondering idiot!
 

bigbaldguy

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cbmedic,
I definitely see where you're coming from on this. The first time I saw a forced catheterization it was on a disabled teenage girl from a group home and it was very traumatic for both the young girl and the people who took part in it. It really shook me up and I'm pretty sure I felt very much as you do now. In my situation I feel they definitely could have taken a few moments to try and calm the young woman down before strapping her down and doing it. All that said it is necessary that they obtain a clean urine sample often for the benefit of the patient. If they were to sedate the patient it could as mentioned mask the presence of another medication. Like you I wouldn't want to be the person to do it but if you keep in mind it is for the benefit of the patient it might make it a little easier to stomach. Sometimes in a bad situation the best we can do is mitigate the crapiness surrounding the situation. I always think of it this way. If I don't do it the next person who gets tasked with it may have even less care/respect for the patient than I do. So unless it's something that that I think is absolutely abhorrent I just do it and try to make it as pleasant as possible for the patient. Remember that unpleasant can be a very relative term in some situations.

Often in cases of suspected DUI/DWI they need to do the tox screen for purposes of a criminal investigation as well. Here in Houston they generally do a blood draw rather than a urine screen for suspected intoxication.

edit : I know someone who once had to help get a blood sample and urine sample from a young woman who had been sexually assaulted after being drugged. She was also very altered/combative and had to be restrained :/ The explanation they received was that the half life in some drugs used in sexual assaults are so short that even a minimal delay can be the difference between proving a person was drugged or not drugged. I was told something similar by a SANE nurse once as well. Not applicable in this situation but something to keep in mind in situations like this.
 
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VFlutter

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Don't most hospitals also have lidocaine lube for foley insertions?

I will take a look next time I am at work but as far as I know it is just regular lube without lidocaine.

Sometimes we try to use condom catheters as an alternative but they just do not work as well and usually come right off if they patient is combative
 
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bigbaldguy

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I will take a look next time I am at work but as far as I know it is just regular lube without lidocaine.

Sometimes we try to use condom catheters as an alternative but they just do not work as well and usually come right off if they patient is combative

The ones I've seen do not have lidocaine in them.
 

Aidey

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Maybe it is one of those things that is an option if it is felt it is needed. I know I've heard it mentioned by the ED nurses.
 
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cbmedic

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I can't imagine you having gone through RN training and not seeing that catheterization is relatively harmless and painless to the patient. No more so than an IV, though I definitely have the same personal opinion as linuss!

I'm wondering if you thought the order for catheterization was to punish the pt.

I'm wondering how your refusal to follow up on a Drs. orders turned out for you.

I'm wondering if you felt you could get an adequate urine sample from a combative patient in restraints. Did you thing you could?

Guess I'm just a wondering idiot!





1: Catheterization is relatively harmless and painless to the patient.... UNLESS it is forced upon the patient blatantly and flagrantly against his will as he screams and writhes.

2. Yes, in fact, I did feel it was somewhat punitive.

3. I do not yet know what my refusal will entail. But I will stand by my decision.

4. I am an advocate for patients' rights.

5. "Guess I'm just a wondering idiot!" I couldn't have said it better.
 

Veneficus

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3. I do not yet know what my refusal will entail. But I will stand by my decision.

Can't speak for where you work, but all the places I have been, we would just sigh and ask somebody other than the new guy to do it.

I have put in more than my fair share of "combat catheters" and it seems to me the "pain and suffering" is mostly psychological.

I have actually written recently about punitive action, we will see if it gets published.

However, it may be the attitude portrayed that makes it seem "punitive."

From the medical standpoint, the patient is altered and does not have decision making capability. Urine tox must be determined in order to best serve the patient.

I would say the patient is just going about things the hard way.
 

Handsome Robb

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Cath him.

His decision to get loaded on whatever he was on, now he has to face the music. If you're blasted to the point that you end up in the hospital you don't have much dignity left to lose. Call me an :censored::censored::censored::censored::censored::censored::censored: but it's true.

Like others have said it's now a diagnostic issue and they're going to need a sample for UA and a catheter is the easiest way to do that. Unless you want to volunteer to stand in the room with a cup and try to catch the sample....have fun with that ;)
 

Veneficus

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Unless you want to volunteer to stand in the room with a cup and try to catch the sample....have fun with that ;)

Vene's rule of EMS #1.

"Never wrestle with a man holding a lightsaber."
 

Medic Tim

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Two nights ago, a drunk/intoxicated patient was brought into the ER. He was violent, and security put him into four point restraints. His clothes were cut off. I was one of the attending RN's, and I was ordered to catheterize him. I refused. I said I would not cath him unless he was sedated, to spare him any pain or humiliation. I was told that the MD would not introduce any drugs into his system until urinalysis results came in.

What would you have done in this situation?

1: Catheterization is relatively harmless and painless to the patient.... UNLESS it is forced upon the patient blatantly and flagrantly against his will as he screams and writhes.

2. Yes, in fact, I did feel it was somewhat punitive.

3. I do not yet know what my refusal will entail. But I will stand by my decision.

4. I am an advocate for patients' rights.

5. "Guess I'm just a wondering idiot!" I couldn't have said it better.

I love when people come here asking what if questions and then when others question them they get pissy.

What the MD ordered was standard for this type of pt. Refusing only "prolonged the pt's pain and humiliation" as you say. The reason why sedation and other drugs are not given has already been explained.

Why do you feel it was a punishment?
Was this the first time you have encountered this kind of situation? if not how was it handled differently?
How would you have handled it knowing that drugs would affect the lab results?
 
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