On Protocols, Shortcuts, and the Unforgettable Smell of EtherNovember 9, 2011
By Linda Johanson, EdD, RN, associate professor of nursing at Appalachian State University, Boone, NC
In nursing school my professors warned us of the dangers of taking shortcuts when performing procedures. They cautioned that deviations from protocols could lead to serious error. I had to learn this lesson the hard way, and although it’s been about 30 years since I made this mistake, I still remember the occasion like it happened yesterday.
The patient was in ICU bed #10, a glassed-in isolation room across from the nursing station. He was in his mid-60s, but he was mentally handicapped, so he appeared and acted younger. He was in the unit recovering from a respiratory arrest, and on the day I was caring for him he was still intubated, but breathing spontaneously.
I was completing an assessment on him when the charge nurse called to me from the nursing station, and I stuck my head out the door to see what she wanted. She told me there was a new order to remove the patient’s indwelling urinary catheter. I checked my pockets for a 10 mL syringe to perform the procedure but didn’t find one.
When I complained about having to go all the way to the supply room to collect one, the charge nurse queried, “Well, you have scissors, don’t you? You can just cut the catheter with them. The balloon will deflate, and it will pull right out. I’ve done it a hundred times.”
Cut the catheter? I had never heard of that before, but I was a relatively new nurse, so I hadn’t been exposed to a lot of things yet. Of course I had scissors right in my pocket, and I got them out. Was this an example of one of those unacceptable shortcuts we’d been warned about in nursing school? It would sure be quicker and easier than running all the way to the supply room.
I approached the patient, who although unable to comprehend what was happening, seemed to regard me with a trusting expression. I exposed the catheter and opened my scissors to a spot about one inch from its point of entry. I hesitated for one brief second, then snipped the tube. I gave the catheter a little tug, and the patient winced. The tube stayed firmly in place, the balloon obviously fully inflated.
I felt my face becoming hot, and my stomach seemed to sink. I tried once more, a somewhat firmer tug, but it wouldn’t budge. I covered up the patient, walked outside the room and slid back against the wall, closing my eyes and envisioning the end of my short nursing career. The catheter was stuck, and the only access to the balloon was in the garbage. What’s more, urine was coming out of the tube in a steady trickle, with nothing to collect it.
The charge nurse couldn’t believe her tried-and-true procedure hadn’t worked. She handed over to me the unpleasant job of contacting the physician. The physician angrily expressed his disappointment, and said we would now need to consult a urologist. The physician assistant on call for the urology group answered my page. After some angry commentary, he said he would come in, and for a tense 30 minutes I worried and waited.
When the PA arrived, he had an array of wires that he carefully arranged on his workspace, all the while lecturing me about the proper way to remove an indwelling urinary catheter. His idea was to thread a wire through the tunnel leading to the balloon and puncture it. He unsuccessfully tried several sizes, and then retried after bending and manipulating the wires, but all to no avail. We had placed a towel under the dripping, severed catheter, but it remained firmly in place. I had begun to wish I’d chosen a different career.
Disappointed, but not ready to give up, the PA had a new idea: What about drawing up some ether and infusing it into the balloon line with a small catheter? It was conceivable that the gas would expand and pop the balloon. He actually seemed to get excited about trying out his hypothesis. As he opened the can containing the ether, I was struck by the pungent smell. The olfactory sense has excellent memory, and I found myself recalling the trauma of my first surgery, at age three for strabismus, when they’d used ether as an anesthetic agent. The horror of this whole incident was just about overwhelming.
The first instillation of the ether didn’t work, but he tried some more, and the balloon finally did pop, allowing him to successfully remove the catheter. It was approximately two hours since I’d first cut the tube, but it felt like a long time to me, and I never wanted to experience anything like it again.