Bladder Catheterization

Ronald Bergman, Ph.D.

Peer Review Status: Internally Peer Reviewed

A Sailor aboard a supply ship in the Red Sea reported to sickbay and told the hospital corpsman
on duty that he was having great difficulty urinating and that his bladder was full and he could
not adequately relieve himself. His distress was obvious. The corpsman donned sterile gloves
and then tapped the Sailor's lower abdomen verifying the full bladder. He told the Sailor that he
would empty his bladder by catheterization (see accompanying illustrations). Hearing this, the
Sailor became very anxious. His anxiety was greatly lessened when the corpsman explained to
him that the procedure might look painful but actually was not. In addition, the relief he would
feel would worth any discomfort he might feel.


Anaseptic wash of urethral opening of penis.

Insertion of catheter.
In order to catheterize the Sailor the corpsman swabbed the urethral opening of his penis with a
non-irritating antiseptic. Taking a sterile catheter lubricated for about two inches he inserted it
slowly into the urethral meatus (opening), he encountered a slight resistance at the sphincter
located in the urogenital diaphragm, then it moved easily through the prostatic urethra into the
bladder. A flood of urine entered the collection bag. The corpsman taped the catheter tube to the
Sailor's abdomen to secure the collection bag. The corpsman told the Sailor that a physician
would take over his case and prescribe a course of treatment for his problem.

Recovery of urine.
Catheterization is essentially the same in both male and female; the catheter, by traversing the
urethra, enters and drains the bladder. The anatomical route is shorter in the female patient but
must be understood in order to effectively perform the catheterization procedure.











Choking
Ronald Bergman, Ph.D.
Peer Review Status: Internally Peer Reviewed

A squad of Marines was celebrating the end of prolonged and strenuous maneuvers with a steak
dinner. During the meal, one of the Marines stood up clutching his throat, his face turning red.
The choking sign was clearly understood; he was unable to speak and he had severe difficulty
breathing. The treatment to follow will be considered in 5 scenarios:

Immediately the Marine began coughing. A piece of meat flew out of his mouth and the Marine
began to breathe normally. This ends the 1st scenario.

Immediately the Marine thrust his abdomen on the top of a chair back. A piece of meat flew out
of his mouth and the Marine began to breathe normally. This ends the 2nd scenario.
Standing thumper
Immediately a corpsman assigned to the squad asked, "Are you choking?" The Marine nodded.
The corpsman gave 3 backblows between the shoulder blades to the Marine with the man in a
bent over position. A piece of meat flew out of his mouth and the Marine began to breathe
normally. This ends the 3rd scenario.
Standing Hemilich If pregnant
Immediately a corpsman assigned to the squad grabbed the Marine from behind, between the ribs
and the umbilicus (belly button), and gave several strong thrusts or squeezes to the Marine's
abdomen (Heimlich maneuver). A piece of meat flew out of his mouth and the Marine began to
breathe normally, the red skin color decreased, the heart rate decreased and the panic subsided. If
pregnant, the corpsman would give the thrusts mid-sternum. This ends the 4th scenario.

The methods outlined above, coughing, backblows, and abdominal thrusts (Heimlich maneuver)
have a very high rate of success. In the event, however, that these methods fail to dislodge the
obstructing material from the air pipe (trachea), a tracheotomy must be considered.


If the choking victim is without oxygen for 4 to 5 minutes he may die or have severe brain
damage, if he survives. Tracheotomy is the last resort - the very last resort - a matter of life or
death. In order to be successful, several common sense things must be kept in mind.



Immediately a corpsman that was present for dinner asked one of the Marines to keep time for
him and call out the time by the minute. He tried the Heimlich maneuver several times and after
this failed to dislodge the obstruction the choking victim became unconscious. The corpsman
then palpated the thyroid cartilage and found the "Adam's apple" or laryngeal prominence. The
corpsman then traced the cartilage distally in the midline straight down until it ended (about 2.5
cm. or 1 inch). The hard cartilage gave way to a membrane (soft spot), the cricothyroid
membrane. It is this membrane that must be opened (see diagrams). (Elapsed time - one minute)
The skin was opened with a sharp knife in the sagittal plane (up/down). Pulling the cut surfaces
apart (right/left) he quickly examined the exposed area for blood vessels and parts of the thyroid
gland. (Elapsed time - two minutes) Avoiding blood vessels and glandular tissue he punctured
the cricothyroid membrane with a knife (very carefully and never transversely) (or he could have
used a sharp pencil or ball point pen), to enter the trachea. The depth of the puncture should be
just sufficient to gain access to the airway. No more than a half-inch or about 1.25 cm. To
maintain the opening to facilitate breathing, a soda straw or tube was placed in the opening.
(Elapsed time - three minutes) The duty corpsman said he was told by a physician about "the rule
of three" - something easy to remember and to be on the safe side - three weeks without food and
you die; three days without water and you die; but only three minutes without air and you die.
The Marine was then taken to sickbay for further treatment. The entire procedure took less than 4
minutes. The opening of the airway allowed the Marine to get the oxygen needed to survive. This
ends the 5th scenario. Remember that tracheotomy is the last resort to restore respiration but; the
alternative is death.

Dangers of anatomic variations covering the cricothyroid ligament


Sucking Chest Wound
Ronald Bergman, Ph.D.
Peer Review Status: Internally Peer Reviewed

A Marine on patrol in the desert felt a sharp pain in his chest and had difficulty breathing; he
called for a corpsman and then collapsed. He had sustained a penetrating bullet wound to his
chest on the right side. Air had rushed into his chest and his right lung collapsed. The corpsman
recognized the seriousness of this life-threatening wound and knew that the Marine was
breathing with one lung. He cut away the Marine's shirt and looked for entrance and exit
wounds; he found only an entrance wound. Bleeding was minimal but uncontrollable. The
corpsman recognized that on inspiration air entered the opening in the chest caused by the bullet
and, on expiration, air was forced out of the thoracic cavity (see illustrations). He prepared a
sterile occlusive dressing that was taped securely to the chest over the wound on 3 sides. One
edge was not taped leaving an opening to the dressing. He knew that this would act as a "valve"
and on inspiration the occlusive dressing would be drawn tightly to the chest by the negative
pressure (hence the name "sucking wound"). External air is excluded. On expiration, the air
forced out of the thorax escapes at the unsealed edge of the occlusive dressing. Had the
corpsman found an exit wound he would have dressed the wound in the same way. As soon as
the corpsman finished with the dressing he covered the Marine with a jacket to reduce shock. He
called for a stretcher and because of the life-threatening nature of the wound, he had the Marine
airlifted by helicopter to a hospital ship lying off shore. He was immediately taken to a navy
surgeon for the definitive treatment that is only available in the hospital.


Injury to Thigh
Compound (Open) Fracture of Femur
Use of Tourniquet
Ronald Bergman, Ph.D.
Peer Review Status: Internally Peer Reviewed


On an aircraft carrier in the Persian Gulf, flight deck personnel were readying fighter aircraft for
a strike at enemy ground forces. One of the Sailors had a problem with ordinance and one rocket
accidentally discharged. The rocket flew into and past another Sailor causing severe injury to his
thigh and fracturing his femur. Ruptured femoral vessels poured forth blood and the injured
Sailor fell to the deck unconscious. An alert Sailor called for someone to summon the corpsman
and then he dropped to the deck to close off the blood loss by use of a tourniquet. Very shortly
afterwards the corpsmen arrived. The corpsman checked the tourniquet (see accompanying
illustrations), and wrote on the forehead of the victim the time of application of the tourniquet.
The Sailor was covered with a blanket to reduce the possibility of severe shock and the wound
was covered with sterile, moist gauze. The injured Sailor's vital signs were taken (pulse, blood
pressure and respiratory rate) as he was taken rapidly to the sickbay. In the meantime, the naval
surgeon was summoned to sickbay, which was readied for treatment of the injured Sailor. If this
accident had happened on shore, the corpsman would have followed the same procedures but
would have had to immobilize the leg with a splint. The splint, in combat, might include a branch
of a tree or any other inflexible object (preferably clean) a pillow, magazine or newspaper as the
supporting structure. The two legs can be merely bound together. The rationale is to avoid
causing further damage by the sharp edges of the fractured bones moving about while the patient
is being evacuated.
The following are useful guidelines when one considers the possibility of broken bones. A
corpsman may use the following signs as indicators of broken bones:
1. Pain or soreness over a joint or bone.
2. The victim tells the corpsman that he heard or felt a break.
3. The victim can't move an injured part or that a move is painful.
4. The victim tells the corpsman that there is numbness or tingling in the injured limb. This is
also an indicator of possible nerve injury.
5. An arterial pulse cannot be found in the injured part or limb. This is an indicator of blood
vessel injury.
6. The corpsman sees swelling or bruising in the injury site. This an indicator of extravasated
blood.
7. The injured part is in an unusual or abnormal position and any possible movement is
abnormal.
How to provide first aid to victims with bone or joint injuries? Without x-rays or MR imaging it
is not always possible to know if a bone is broken, a joint is dislocated or damaged, or if
ligaments are stretched or torn. The rule-of-thumb therefore, is not to guess, but to immobilize
the injured part. However, this is not the first step in the first aid of these victims.
1. Treat for any life-threatening condition first: check breathing, pulse and for any bleeding.
Finally stabilize the fractured bone or injured joint.
2. It is essential to keep movement of the individual and the injured part to a minimum. The
rational for minimal movement is to reduce the possibility of additional damage to bone, muscle,
blood vessels and nerves and the production of additional pain.
3. Immobilize the injured part with bandages, slings and splints.

4. If there is torn skin avoid contamination of exposed underlying structures using sterile
compresses. Infections of bone are very serious and difficult to treat. If there is a compound or
open fracture (bone sticking through the surface of the skin) never try to push the bone inside the
torn muscle.
5. Swelling of joints can be avoided by cooling the injured part using ice wrapped in a cloth or
towel.
6. Treat for shock and secure the aid of a medical corpsman and physician as soon as possible.




Colle's fracture

Comminuted fracture

Green-stick

Impacted

Incomplete

Linear

Oblique

Pott's fracture

Spiral fracture

Transverse fracture






















Urinary catheters
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A urinary catheter is a tube placed in the body to drain and collect urine from the bladder.
Information
Urinary catheters are used to drain the bladder. Your health care provider may recommend that
you use a catheter if you have:
Urinary incontinence (leaking urine or being unable to control when you urinate)
Urinary retention (being unable to empty your bladder when you need to)
Surgery on the prostate or genitals
Other medical conditions such as multiple sclerosis, spinal cord injury, or dementia
Catheters come in many sizes, materials (latex, silicone, Teflon), and types (Foley, straight,
coude tip). A Foley catheter, for example, is a soft, plastic or rubber tube that is inserted into the
bladder to drain the urine.
Usually your health care provider will use the smallest possible catheter.
There are three main types of catheters:
Indwelling catheter
Condom catheter
Intermittent (short-term) catheter
INDWELLING URETHRAL CATHETERS
An indwelling urinary catheter is one that is left in the bladder. You may use an indwelling
catheter for a short time or a long time.
An indwelling catheter collects urine by attaching to a drainage bag. A newer type of catheter
has a valve that can be opened to allow urine to flow out.
An indwelling catheter may be inserted into the bladder in two ways:
Most often, the catheter is inserted through the urethra. This is the tube that carries urine from the bladder
to the outside of the body.
Sometimes, the health care provider will insert a catheter into your bladder through a small hole in your
belly. This is done at a hospital or health care provider's office.
An indwelling catheter has a small balloon inflated on the end of it. This prevents the catheter
from sliding out of your body. When the catheter needs to be removed, the balloon is deflated.
CONDOM CATHETERS
Condom catheters are most often used in elderly men with dementia. There is no tube placed
inside the penis. Instead, a condom-like device is placed over the penis. A tube leads from this
device to a drainage bag. The condom catheter must be changed every day.
INTERMITTENT (SHORT-TERM) CATHETERS
You would use an intermittent catheter when you only need to use a catheter sometimes. You
remove these catheters after the flow of urine has stopped.
DRAINAGE BAGS
A catheter is usually attached to a drainage bag. There are two types of bags:
A leg bag is a small device that attaches by elastic bands to the leg. It holds about 300 to
500 milliliters (ml) of urine. You wear it during the day, because you can hide it under
pants or a skirt. You can easily empty it into the toilet.
You can use a larger drainage device during the night. It holds 1 to 2 liters of urine. You
hang the device on your bed or place it on the floor.
Keep the drainage bag lower than your bladder so that urine does not flow back up into your
bladder. Empty the drainage device at least every 8 hours, or when it is full.
To clean the drainage bag, remove it from the catheter. Attach a new drainage device to the
catheter while you clean the old one.
Clean and deodorize the drainage bag by filling it with a mixture of vinegar and water. Or, you
can use chlorine bleach instead. Let the bag soak for 20 minutes. Hang it with the outlet valve
open to drain and dry.
HOW TO CARE FOR A CATHETER
To care for an indwelling catheter, clean the area where the catheter exits your body and the
catheter itself with soap and water every day. Also clean the area after every bowel movement to
prevent infection.
If you have a suprapubic catheter, clean the opening in your belly and the tube with soap and
water every day. Then cover it with dry gauze.
Drink plenty of fluids to help prevent infections. Ask your health care provider how much you
should drink.
Wash your hands before and after handling the drainage device. Do not allow the outlet valve to
touch anything. If the outlet gets dirty, clean it with soap and water.
Sometimes urine can leak around the catheter. This may be caused by:
Catheter that is blocked or that has a kink in it
Catheter that is too small
Bladder spasms
Constipation
The wrong balloon size
Urinary tract infections
POSSIBLE COMPLICATIONS
Complications of catheter use include:
Allergy or sensitivity to latex
Bladder stones
Blood infections (septicemia)
Blood in the urine (hematuria)
Kidney damage (usually only with long-term, indwelling catheter use)
Urethral injury
Urinary tract or kidney infections
Call your health care provider if you have:
Bladder spasms that do not go away
Bleeding into or around the catheter
Fever or chills
Large amounts of urine leaking around the catheter
Skin sores around a suprapubic catheter
Stones or sediment in the urinary catheter or drainage bag
Swelling of the urethra around the catheter
Urine with a strong smell, or that is thick or cloudy
Very little or no urine draining from the catheter and you are drinking enough fluids
If the catheter becomes clogged, painful, or infected, it will need to be replaced immediately.










What Are Urinary Catheters?
Urinary catheters are hollow, flexible tubes used to collect urine from the bladder. Urinary catheters come in many
sizes and types. Catheters can be made of rubber, silicone, or latex. The catheter tube leads to a drainage bag that
holds collected urine.
Catheters are generally used when a patient is unable to empty his or her bladder. If the bladder is not emptied, urine
can build up and lead to pressure in the kidneys. The pressure can result in kidney failure, which can be dangerous
and may result in permanent damage to the kidneys.
Most catheters are used for a short period of time, until the patient regains the ability to urinate on his or her own.
Elderly people and those with a permanent injury or severe illness may need to use urinary catheters for a much
longer period of time.
Part 2 of 5: Uses
Why Are Urinary Catheters Used?
A doctor may recommend the use of a catheter if you are unable to control when you urinate, if you are leaking urine
(urinary incontinence), or if you are unable to empty your bladder when you need to (urinary retention).
Reasons why you may not be able to urinate on your own include:
blocked flow of urine due to bladder stones, blood clots in the uri ne, or narrowing of the urethra (the tube that connects your bladder to the
outside of your body)
surgery on your prostate gland or in the genital area, such as a hip fracture repair or hysterectomy
injury to the nerves of the bladder
spinal cord injury
a condition that impairs your mental function, such as dementia
medications that impair the ability of your bladder muscles to squeeze, which causes urine to remain stuck in your bladder
Part 3 of 5: Types
What Are the Types of Urinary Catheters?
There are three main types of catheters, described below.
Indwelling Catheters (Urethral or Suprapubic Catheters)
An indwelling catheter is a catheter that is left in the bladder. It may also be called a Foley catheter. This type can be
used for both short and long periods of time. An indwelling catheter is usually inserted into the bladder through the
urethra.
Sometimes, a doctor will insert the catheter into the bladder through a tiny hole in the abdomen. This type of
indwelling catheter is called a suprapubic catheter.
A tiny balloon at the end of the catheter is inflated to prevent the tube from sliding out of the body. The balloon is
deflated when the catheter needs to be removed.
External Catheters (Condom Catheters)
A condom catheter is a catheter that is placed outside the body. They are typically used for men who do not have
urinary retention problems, but have serious functional or mental disabilities, such as dementia. The tube is not
placed inside the penis. Instead, a device that looks like a condom is placed over the penis head. A tube leads from
the condom device to a drainage bag.
These catheters are generally more comfortable and carry a lower risk of infection than indwelling catheters. Condom
catheters need to be changed daily.
Short-Term (Intermittent) Catheters
A short-term catheter is recommended for short-term use when a patient needs one after surgery. It is typically
removed right after the bladder is emptied.
Part 4 of 5: Complications
What Are the Potential Complications of Urinary
Catheters?
Indwelling urinary catheters are the leading cause of healthcare-associated urinary tract infections (UTIs) (van den
Broek, et. al., 2011). Therefore, it is important that catheters are routinely cleaned to prevent infections. Symptoms of
a UTI may include:
fever
chills
headache
burning of the urethra or genital area
leaking of urine out of the catheter
blood in the urine
foul smelling urine
low back pain and achiness
Other complications of urinary catheter use include:
allergic reaction to the material used in the catheter, such as latex
bladder stones
blood in the urine
injury to the urethra
kidney damage (with long-term indwelling catheters)
infection of the urinary tract, kidney, or blood (septicemia)
Part 5 of 5: Proper Care
How Do You Care for a Urinary Catheter?
Care must be taken to clean both the catheter and the area where the catheter enters the body with soap and water
to reduce the risk of a UTI. In addition, you should drink plenty of water to keep your urine clear or only slightly yellow
in color to help prevent infection.
The drainage bag used to collect the urine should be emptied at least every eight hours and whenever the bag is full.
The drainage bag should be cleaned using a plastic squirt bottle containing a mixture of vinegar and water or bleach
and water.