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On Protocols, Shortcuts, and the Unforgettable Smell of Ether

November 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.

by james bowe, via flickr

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.

It was a hard lesson, but from that day forward I have very clearly understood the rationale for always following protocol and checking reliable sources about unfamiliar procedures.

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9 comments

  1. What will happen if we cut the catheter but not at colour pot.. But cut at the junction…it will function same or not…

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  2. Nurses have the great responsibility of caring for the precious gift of life. As new nurses we may be exposed to different situations in which more experienced nurses teach us “shortcuts” while performing nursing procedures. It is critical that we make sure we are following protocol in order to provide quality care for our patients and avoid putting them in danger. The new nurse in this story was advised to cut the indwelling urinary catheter with scissors in order to deflate the balloon and remove it. She took the “shortcut”, however the balloon didn’t deflate. The lesson for all of us new nurses entering the nursing arena excited to put our knowledge into practice is that we must be able to maintain the safety of our patients as a priority and always follow protocols and avoid “shortcuts”.

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  3. I remember you telling us that story… Interestingly enough, that just happened to a nurse when I was working on Friday! I shall print this and put it in the break room!

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  4. Lesson learn. Will you ever make that mistake or anything like it again? No way? Some thing good that did come out of it. I always go by two things; my gut, what does my gut feel? And would I want someone doing the samething to a grandparent of mine. If I wouldnt, than I wouldn’t have performed that type of care. I was also taught by a wise nurse, listen to your gut!!!!

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  5. Thanks for clarifying. It’s not the author’s fault. She had just used PA, and we (I, the editor) spelled it out. We’ll fix that to read “physician assistant.” We think details matter a great deal, actually.-JM

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  6. The proper title is Physician Assistant not Physician’s Assistant. Small detail….but yes it does matter to most PAs. Being respectful with their title is a small price to pay for the respect for our generally long list of postnominal credentials….

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  7. Ahhh, yes! A great example of a seasoned nurse (who probably learned this shortcut in the very same way) giving advice to a new nurse. Notice I said “advice,” not good advice, not mentoring, not educating… this happens way too often and I’m not sure how we as a profession can fix this. Anyone have good ideas?
    As a nurse with many, many years of experience, I am guilty of giving shortcut advice and doing shortcuts or jury-rigging devices to do what I wanted them to do. Although many of these ideas work, they still usually work around policy or protocol that is there for a reason.
    In my current position I promote “best” and evidence based practice. How do we determine this in nursing when often there is no evidence??
    It’s a dilemma that we must solve. Any ideas?

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  8. I think after that I would have left nursing for good. What a nightmare!

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  9. Excellent example of a repercussion from a shot cut :) Actually I have seen this happen more than once – The water balloon lumen is pinched together and occluded by the scissors. Thankfully cutting the catheter again above the original cut resulted in success. Still, I would not recommend this common shot cut.

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