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Thursday, February 18, 2010

Emergency Department experience and CBD insertion

This post is not for educational purpose, just for sharing my very own experience in handling the procedure. I was flipping through the OSCE guidebook prepared by my seniors based on the common questions asked for OSCE in final MBBS examination. Then I came across the page where the step by step method of continuous bladder drainage (CBD) insertion is explained. All of sudden the memory of my first CBD insertion came to my mind. It was awful, both to myself as well as the patient (or the 'victim', I might say). I felt sorry for the patient, but unfortunately there will always be the first time in everything, isn't it?

I was in the Emergency department doing my emergency medicine posting. I was the only medical student available. It's not that I am extra hardworking or diligent. It's just that most of the boxes of signatures for my logbook procedures were empty! But I am grateful to be around on that night, because I learned a lot from the doctors and other healthcare staffs.

That night was exceptionally quiet with not much patients. So I went to the observation ward just in case the doctors there require extra hands. One of the MOs there noticed my presence and asked me to join in. She even showed my some findings in the X-rays etc. She also told me that it is always like that in the ED (emergency dept, not erectile dysfunction) during weekends. Wait until about 1-2 a.m. and surely the department will become "merrier". At first I was puzzled, but just as I was about to ask, she told me, "that is when the clubs and pubs closed".

"Oh... drink and drive after the happy hour, I guess..." came across my mind... And she was right. As I was about to leave the ED a few hours later, I was told by the staff at the reception counter there was an accident involving a motorcyclist- allegedly drunk. So I followed the ambulance and help the paramedics to bring him to ED. After resuscitation done and serious injuries being ruled out, I was asked by a doctor to set in the CBD for the patient. I was stunned as I never did it before! I was fortunate that one of the staff nurses was willing to guide me.

1) Make sure you are well prepared. For a list of equipments required, please click HERE

2) Try to be as sterile as you can (of course it's impossible to have 0% bacteria in such environment). Wash your hand properly.

3) Don't forget to ask for patient's consent. I was told that for this instance, verbal consent is acceptable.


4) Decide the size of the Foley's catheter accordingly. For adults use FG 12 (French Gauge).


5) Make a hole in the middle of a drape and set it upon the patient's private part, with the hole exposing the genitalia.


6) Wear sterile gloves and the clean the genital using cotton wool soaked with normal saline.
Note: Use forceps to hold the cotton wools

7) Insert lignocaine gel into patient's urethral orifice.


8) Apply KY jelly to the tip of the catheter and insert it into the orifice carefully. Inform the patient first about the discomfort / mild pain and tell him to calm down. Breath in and breath out. Be careful not to cause trauma.


9) Once the catheter is inserted accordingly, inflate the balloon using 10 ml of normal saline.


10) Pull the catheter slowly to see whether the balloon was inflated to prevent the catheter from being dislodged.


11) Attach the tube to the CBD bag.


12) Clean up after finishing the procedure.




It was messy. Seriously. The staff nurse was called by the doctor at the next bay, so I was all alone for this 'challenge'. The lignocaine gel spilled over my gloves and I had difficulty to hold the penis as I inserted the catheter. Slippery. And this has caused further discomfort to the patient. When I was trying to inflate the balloon, the normal saline splashed because the connection between the catheter and the 10ml syringe was not properly attached. Thank God I managed to avoid the splash, but the drape was soaked with it. I had to refill another 5ml to make sure the balloon was adequately inflated. I managed to clean up before the staff nurse came back to the bay and before the doctor came to review the patient's progress. Sigh...

But the nightmare was not over. Another doctor came and asked me to set another CBD. "Dah pandai kan... Buatlah ye. Saya ada kerja sikit," (Now that you are used to it, you can do it by yourself. I have some work to do) said the staff nurse before he left the bay to the reception counter.

"Err... sure..."

p.s. The second CBD insertion was much better as compared to the first though... =)



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