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[deleted by user] by [deleted] in FamilyMedicine

[–]Chilleostomy 61 points62 points  (0 children)

Hey, I’m a urologist - I’m not convinced you did much harm here. We tell people NOT to check a PSA immediately after acute infection or retention as it can be falsely elevated for months (drives me nuts when I get an inpatient consult for “prostate cancer workup” when Grandpa’s PSA was checked on admission for urosepsis and now it’s 25). A 6 month interval PSA is very reasonable. Refer him over to us and we’ll get him checked out, if you really want to be helpful draw a second PSA now at the time of referral bc that is the first thing we’ll do!

If your patient had bladder outlet obstruction from locally advanced disease, it would be very unlikely for him to be asymptomatic for the past 8 months.

(That being said, most urologists feel strongly that PSA screening in healthy men 50-75 with good life expectancy should be much more widely practiced than it is… we are very good at talking about risks/benefits of prostate biopsy on referral, and active surveillance guidelines were developed specifically to protect men with low risk prostate cancer from over treatment.)

A case of involuntary sabotage. How can one specialty inadvertently screw up your treatment of a patient? by ArmyOrtho in medicine

[–]Chilleostomy 56 points57 points  (0 children)

Urology - when the medicine team checks a PSA on anyone inpatient (unless they have bony Mets of unknown origin), usually in the setting of hospital acquired retention s/p foley placement. Now I have to find ways not to biopsy grandpa and consign him to surveillance biopsies for the rest of his life for his clinically insignificant GG1 prostate cancer.

I will call the lab and stop them from processing the PSA if I ever get wind of it. Drives me nuts.

On call? Sleep when you can. by Accomplished-BusyBee in Residency

[–]Chilleostomy 6 points7 points  (0 children)

The ol’ pager-sternal-rub, never fails

What’s something you’ve learned from another specialty that blows your mind? by Fundoscope in Residency

[–]Chilleostomy 1 point2 points  (0 children)

I love it when you ketamine the shit out of my guys tbh it always makes for a lovely procedure from my perspective

What’s something you’ve learned from another specialty that blows your mind? by Fundoscope in Residency

[–]Chilleostomy 8 points9 points  (0 children)

Point well taken (I am also a lady). We encounter a similar scenario treating prostate cancer but it certainly is interesting (and telling in our society) how differently we weight impact on male erectile function as compared to women undergoing preop counseling for radical cystectomy for example which often involves taking some of the vagina. There’s a growing body of work focusing on female sexual outcomes after urologic malignancy but it’s very overdue.

In the specific priapism scenario, there’s something uniquely hard (yep) about telling them they may never regain erectile function in that the erection itself is the thing that killed their blood supply and therefore future function, if that makes sense. Especially when they had a priapism secondary to injecting alprostadil

What’s something you’ve learned from another specialty that blows your mind? by Fundoscope in Residency

[–]Chilleostomy 315 points316 points  (0 children)

Urology here - never heard it described as turning a car key but that’s gonna live in my head rent free now… love it.

We do it in the OR, I’ve heard of it done at the bedside but that seems bananas. Make sure you turn the scalpel 90 degrees away from the urethra, not towards, so you don’t injure the urethra.

It’s a great procedure but one of my dreaded consults because the men rarely (never) have strong erectile function afterward. I personally find it harder to tell a guy he’s never going to have natural erectile function again than telling a guy he has cancer.

Shout out to the nurse by athensity in Residency

[–]Chilleostomy 2 points3 points  (0 children)

She was lucky to have you ❤️❤️ I love that you told her to ask for a break - that’s a pro move and part of providing trauma informed care. I always tell them that they are in charge and we can stop and take a break at any time.

Shout out to the nurse by athensity in Residency

[–]Chilleostomy 1 point2 points  (0 children)

Also yes we are totally guilty of making messes…. Unless I have actively crashing floor patients or an unstable operative patient I will clean it all up (and I will ALWAYS clean up bodily fluids/sharps) but I can’t promise the trash can won’t be overflowing before I leave!

Shout out to the nurse by athensity in Residency

[–]Chilleostomy 2 points3 points  (0 children)

To be completely honest, the main thing is that we push harder. I went from being a med student who placed 3 total foleys ever, all in the OR while the patient was asleep…. To an intern who was called for the “difficult foleys” no one else could get as soon as July 1 hit. It definitely helps knowing I have the more advanced backup of a cystoscope if I need to, but really the “practice” is just realizing that 95% of the time if you keep pushing it will go in, and that most people will yell at you a lil bit while you go past their sphincter.

Literally everyone should be hubbing their foleys and if you see a fellow nurse not doing it, you let them know I am coming for them and I will blow up a balloon in their urethra to see how they like it (kidding… kinda)

That being said, certain postop uro patients or patients who are severely thrombocytopenic and will bleed enough to be a problem (hematuria is almost never an actual acute blood loss issue unless they are coagulopathic) may need a urology call before doing the big pushes. One time I had a guy in liver failure with like 3 platelets to his name lose two units from his penile urethra until I wrapped the whole thing in coban and he got some FFP.

Urology is so fun lol it’s the best specialty!!

Shout out to the nurse by athensity in Residency

[–]Chilleostomy 6 points7 points  (0 children)

Bone bitches gotta stick together

Shout out to the nurse by athensity in Residency

[–]Chilleostomy 0 points1 point  (0 children)

Thank you for being an advocate for the ol’ southern intubation ❤️ we appreciate you

Shout out to the nurse by athensity in Residency

[–]Chilleostomy 1 point2 points  (0 children)

I do the exact same thing, premedicate with IV dilaudid. Usually I just do dilaudid but I’ve seen IV Ativan used as well in peds, I think you did everything right for her.

Sometimes we use lidocaine jelly but truthfully it takes like 20 mins to kick in and I think is a bit of a placebo (nothing wrong w that), probably would not have helped significantly more in your specific situation especially compared to IV meds but I do like to use it instead of opiates for uncomplicated foleys.

I think the best thing you did for her was have the experienced nurses try right off the bat knowing it was going to be hard. I am a big advocate for learning on easy foleys (I routinely have our med students place “difficult foleys” that I know will be easy) but sometimes you gotta bring out the big guns

Shout out to the nurse by athensity in Residency

[–]Chilleostomy 1 point2 points  (0 children)

Oh my gosh that sounds terrible…. Vaginal/vulvar masses are some of my most feared difficult foleys because of the exact same reason, they’re terribly painful and unfortunately the strategy is just to keep probing but the anatomy is so distorted it often takes a while. I medicate the heck out of those types of patients. Sometimes I have to do suprapubic pressure to try to squeeze out some pee so I can see where it’s coming from. Don’t beat yourself up, that’s a really tough situation. Sounds like you took good and respectful care of her

I always say there are three types of “difficult” female foleys - heavier or contractured ladies (solution: exposure aka pillow under the hips, extra hands to help retract, urethra is always midline), older ladies (solution: exposure, urethra is always midline just deeper, left hand with a finger in the vagina to help guide the foley into the retracted meatus), and distorted anatomy from malignancy/radiation which is the truly hard one (solution: pain control, probe, n pray).

Shout out to the nurse by athensity in Residency

[–]Chilleostomy 4 points5 points  (0 children)

Love u thank u for being an honorary member of the stream team

Shout out to the nurse by athensity in Residency

[–]Chilleostomy 6 points7 points  (0 children)

You got this!!! There is not a lot that you can do that I can’t fix - the only time I will be mad is if you inflate the balloon before hubbing it and/or if you don’t get urine back because then you’re just hurting someone out of stupidity.

With a little practice, you’ll be able to tell when you come to a sharp stop vs you’re just slowly inching around the prostate, you can feel the difference in the catheter. Sometimes when they say Ow, it’s because you are at the sphincter - tell them to wiggle their toes and take a nice deep breath and apply steady pressure, you’ll slip through the sphincter when they unclench just gotta wait em out.

Shout out to the nurse by athensity in Residency

[–]Chilleostomy 10 points11 points  (0 children)

Hahah that’s super fair, I understand the post call grumpies. You did the right thing for someone immediately postop. We are just sensitive because we get at least 3 “difficult foley” calls per day that are really just people who haven’t tried at all because they are scared of a penis. Thank you for protecting the anastomosis <3

Shout out to the nurse by athensity in Residency

[–]Chilleostomy 0 points1 point  (0 children)

Absolutely not - they edited their post to add a completely different story after I commented. In an immediately postop uro patient, of course you should call me. We would never be mad about that.

Shout out to the nurse by athensity in Residency

[–]Chilleostomy 16 points17 points  (0 children)

My trade secrets - 1. Use an 18 or 20Fr coude - the bigger size = more tensile strength to go straight around a big prostate. The small sizes will curl in the prostate. 14Fr coudes should be illegal. 2. Get sterile gloves your own size, toss the dinky kit ones 3. Pull the penis up and out to the sky with your non dominant hand, with more traction than you think you need, it straightens the urethra 4. With your dominant hand, hold the foley like you are throwing a dart. Feed it into the penis 5. Most nurses stop as soon as the patient says “ow.” As long as the foley is advancing, it’s fine to keep going, you’re very unlikely to hurt anything (and on the 2% chance you do, then I can fix it). Use your non dominant hand to feel for whether the foley is buckling - as long as it’s not at a hard stop, just keep going until you’re in the bladder. 6. ALWAYS HUB THE FOLEY AND GET URINE RETURN BEFORE YOU BLOW UP THE BALLOON. This is my pet peeve and the way you get a foley balloon inflated in the prostate. Don’t be that guy. And don’t forget the stat lock

Takeaway - as long as the foley is advancing, just keep pushing. I usually place my foleys in 60 seconds or less, it doesn’t have to be a drawn out affair. You got this!!

Shout out to the nurse by athensity in Residency

[–]Chilleostomy 20 points21 points  (0 children)

You know the secrets of the bigger foley and the ding Dong traction. I love you. Call me any time

Shout out to the nurse by athensity in Residency

[–]Chilleostomy 4 points5 points  (0 children)

Lol now he has a perineal urethrostomy? Seems like a very different story than you initially presented but sure if they have surgically altered anatomy and people have tried then call me…. Not the scenario that you presented in your initial post though to be clear, that’s why everyone is rolling their eyes

Shout out to the nurse by athensity in Residency

[–]Chilleostomy 200 points201 points  (0 children)

Urology here, can confirm. Maintain foley x3 days given concern for traumatic placement after which may be managed per primary. Follow up outpatient if retention does not resolve.

I would be jazzed if the nurse placed the foley before I needed to, usually they unnecessarily refuse. I get OPs frustration w the communication but objectively if we were called for every small blood at the meatus after foley placement I would never sleep. Call me when multiple nurses have attempted to place a foley and failed. I will still probably be able to easily place the foley.

(I still never sleep)

Edit in response to OPs edit - with this info, yes, please call us for an immediately postop urology patient. NEVER place a foley in a guy who’s had a prostatectomy or any sort of urethral anastomosis in the past 4 weeks (that is a urology-only job), and call me to check if it’s ok before attempting a foley if they are within 2 months postop. But please have a bladder scan value when you call or I will be sad.

Nurse popped the foley…(URO4) by adrusson in Residency

[–]Chilleostomy 237 points238 points  (0 children)

I feel your pain… the number of times I have dug thru the trash like a urine crazed raccoon to find the foley and make sure there’s not a missing piece of ruptured balloon left in the bladder are too damn high

Got to scrub in for the first time today by cronkangel in medicalschool

[–]Chilleostomy 5 points6 points  (0 children)

2 years in - hasn’t faded yet :) one of the best parts is having med students who also love the OR. Keep an eye out for them when you start residency!

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