Grand Geyser

Doctors often place catheters in patients who have problems emptying their bladders. The catheters are frequently placed directly through the urethra but, if they are going to be in place for a long time, a suprapubic catheter is often placed. It is called this because it is placed through the skin, just above (supra-) the pubic bone, directly into the bladder. The urine leaves the bladder through the catheter and is stored in a bag, which is emptied as needed.

Patients with suprapubic catheters are at increased risk of urinary tract infections since we were not designed to have a rubber tube going through our skin into our bladders. When such patients come into the emergency department with fever, we send urine to the laboratory to test for infection. We don’t just send urine out of the bag, however, because it has usually been sitting there for a long time and is over-grown with all kinds of bacteria. In order for the test to be accurate, we remove the catheter, replace it with a fresh one and test the urine that collects in the new catheter and bag.

The other night, I had a patient from a nursing home with fever, low blood pressure, a high pulse – and a suprapubic catheter. A urinary tract infection was high on my list of suspected diagnoses.

Helping me care for this patient was an intern, a doctor working in the hospital during the first year after medical school. I asked her if she had ever changed a suprapubic urinary catheter. When she said she had not, I offered to help her do so.

I told her it was a simple thing to do and verbally took her through the ways in which this is different from placing other catheters, which she had done in the past. One thing I warned her about was that, if the catheter had become plugged, the urine in the bladder could be under pressure and squirt out of the hole in the abdominal wall when the old catheter was removed. I told her I always like to have a towel ready in case that happened.

After explaining to the patient what we were going to do, we positioned her flat in bed and gathered our supplies. We put on sterile gloves and the intern carefully swabbed the area around the old catheter with antiseptic. She slowly removed the old catheter from the hole in the patient’s lower abdominal wall and, as soon as the catheter came out of the hole, a torrent of foul-smelling urine gushed out in a geyser over a foot high. The intern jumped back and I jumped forward. I grabbed my well-placed towel, quickly covering the hole and trying to control the flow of urine. In spite of the towel, the urine flowed out all over the sides of the patient’s abdomen and down between her legs, soaking the sheets and pooling underneath her.

Soon, enough urine had escaped to allow me to move the towel out of the way without risk of being squirted. Now, oozing out of the hole was a thick, yellow-green liquid that looked much more like pus than urine. By then, the intern had gathered her wits and was able to push the new catheter into the hole. Once the balloon on the catheter was blown up, the infected urine started flowing into the catheter rather than out of the hole. We collected a sample to be sent to the lab. The nurse cleaned the patient up and changed her bedding while I went to order antibiotics and arrange for hospital admission.

This was the very worst I have seen urine squirt out when a suprapubic catheter was removed and, for the intern,  was a memorable learning experience to have a handy towel ready.

Note: Grand Geyser, in Yellowstone National Park, is the tallest and most spectacular of the predicted geysers. It erupts from a pool of water making it a fountain-type geyser as opposed to Old Faithful which is a cone-type geyser. Grand’s eruption is about 150-180 feet high and lasts about 10-12 minutes.