"Post procedure infection and treatment"

Infection and treatment following TRUP (transrectal ultrasound and biopsy of the prostate).

Since for at least some of the time I was experiencing feverish symptoms, not all of this account may be entirely in proper sequence or complete.

I was seen for the above procedure as an outpatient by Mr. Lamb in early October. Risks and processes were fully explained, the procedure carried out and an appointment made for feedback on the results (for two weeks later). 

That evening, at home, it became apparent that I might be on of the 2/100 who suffer a post-procedure infection as I had developed feverish shivery symptoms.  Following Mr Lamb's advice I reported immediately to A&E which was very busy. After waiting just over two hours I was taken. This was ahead of some who were there earlier and after some others who arrived later. It wasn't clear to me how the prioritisation process works and at one point all those waiting were advised that there was a 5 hour wait to be seen and anyone who felt able to go home should do so and seek alternative access to medical services in the morning. My wife and I discussed this and I would have gone home and taken more paracetamol had it not been for Mr Lamb's strong advice to go to A&E.  It seemed strange at the time that patients should be asked to decide on their own relative priority. 

The initial screening led to me being taken into one of the examination/treatment booths. A duty doctor  (Dr Rebecca?) came down from urology and the process of examination/treatment (triple antibiotic therapy/catheterisation etc) began. She had a calm and reassuring manner. It was clear that the hospital was under significant bed pressure and I spent the night in A&E. This was a very interesting experience as I was directly opposite the nurses' station. I must commend all of the staff who were working under some pressure that evening. In particular I want to comment one of the staff nurses i/c, Clare, who had a calm and influential authority in all that she did. She was at the heart of that setting, knew all that was going on, was able to keep the system moving, communicating with patients/patient supporters/doctors who came in from other parts of the hospital/other nurses (including nurses shifted in to help). I was very impressed. I also want to mention especially one of the care assistants Anne, who played an important role just in being friendly and supportive when I didn't know what was going on/what might happen next. 

Sometime after 7 I was moved up to what looked like a temporary bed in ITU in among a variety of specialist equipment.  Again I had a front seat view of the nurses' station and again want to commend the nurse(s) particularly Cheryl, who again exuded calm friendly supportive authority in her manner and dealings in all the busy communications and decisions she had to make.  I don't remember the name of the doctor from Urology who came to see me in this bed but she did explain that I was being held so that bloods could be checked to try to identify more precisely the nature of the problem.  During my time in this bed I experienced the profound sense of loss of control that I guess all hospital patients feel at some time or another. An hour without knowing what is next can seem like a day, particularly if, like me, you are admitted without knowing that it was going to happen and so have none of the supports you are used to - things to read, listen to etc.  A smile or a reassuring word from any member of staff (whether a cleaner or a consultant, or those bringing round cups of tea) and any little bit of information about your condition, or the timing of next steps - little reassuring personal touches - can go a long way.  

I was moved again (moving always gives a sense of progress!) to a ward in the Day Medical area. The bed there was facing the toilet door so the opportunities to interact with staff/observe were much fewer and this increased my sense of isolation so I retreated into the books/audio that my wife had been able to bring in for me the previous day. Once again I commend the nurses in charge (in particular Angela and Lauren?) who were highly effective and reassuringly personable in their manner.  I was eager to meet Mr Lamb or whichever other consultant/doctor would inform me of next steps.  Late morning a doctor arrived at my bed and went over the options. He was open to discussion in relation to his initial suggestions and took on board my opinions. As a result, after blood tests were checked, I was to be released that afternoon once drugs etc were sorted out and the date for removal of the catheter was brought forward. 

My overall impression was of a hospital under a lot of pressure from patient need (both A&E and in-patient beds), capable and personable staff and well-understood systems/procedures to manage risk and the complexities of communication. Some staff also showed an admirable 'belt and braces' approach, supplementing the systems with additional 'just in case' advice eg. the nurse in my final ward placement who write out a phone number for me, 'just in case' I was not contacted on the Monday to provide an appointment to remove the catheter.

I offer two comments which may be useful to relevant staff in any review of procedures.

1.  patient management of ongoing procedures post-discharge: in my case, I was discharged with oral tablet antibiotics (easy to manage) and a catheter / leg bag (not very easy to manage). I have found the following aspects of catheter/bag management tricky and describe my experience below, followed by a recommendation for improved patient management.

* keeping a downward path from fluid to flow from bladder through penis to bag while sleeping overnight. This is aggravated where, as in my case, the edge of the mattress is higher than the centre. I have adopted a sleeping position on my side, with the leg to which the bag is attached on the very edge of the mattress and two pillows positioned immediately behind my back preventing me from rolling over to my other side while sleeping. I also only tied the bag to my leg with the top tie, thus allowing the bag to hang down the side of the bed well below the required level. That worked on the first night home but last night, I awoke with an uncomfortable feeling in my penis and realised that I had rolled over onto my back and that (full) bag was now above my leg / bladder with the urine presumably trying to flow back the wrong way. 

*  similar issues to the above while sitting ... I have to sit on the front of the seat and ensure that my left leg (with the bag) is kept below the penis).

*  size of bag: the bag has filled twice each night, despite my drinking less water in the evenings - is a 500 ml bag sufficient?

*  hygiene/cleanliness: having been required to self-catheterise prior to the Holep operation a few years back, I am very aware of the risks of infection being carried into the body from catheters and have washed externally penis/catheter at point of entry. I note that the catheter bag has a space for the person fitting it to write the date fitted and that there is a recommended 5-7 day useage period. In my case, my appointment on Friday will take me to the limit of that 7 day period.  If I had accepted the suggestion made by the Dr that I should bundle together into one my visits to have the catheter removed and to receive feedback on the biopsy, the recommended time would have been considerably exceeded.

In the light of my experience, I believe it would be useful for patients released with a catheter and bag to manage should receive a leaflet of instruction on how to manage the process. A leaflet of this type is available online and can easily be found with google.

 In one such leaflet it mentions a 'G-strap' to hold the tube in place and a 'sock' for the bag. This might help with the occasional discomfort I have experienced with (a) the catheter 'pulling' on the penis when the bag is heavy and (b) the elasticated straps holding the bag in place slipping down the leg and so having to be tightened to such a degree of tightness that it causes discomfort.  As a result of (a) and (b) while I am in the house I am emptying the bag much more frequently so  that it doesn't get heavy at all. 

2. internal communication. I was aware how very important the systems are (and I know anyone reading this will also be aware of this too!!!) so I just want to highlight that point in relation to my case. In my case, I was moved from outpatient (Wed afternoon) to inpatient in A&E (Wed evening to Thurs morning) to inpatient in ITU (Thurs - Friday) and inpatient in Day Medical (Friday-Saturday). In at least some of these locations for some of the time some of the staff were less familiar with the setting, having been drafted in from elsewhere.  The hardcopy folder which contained my case information was obviously important to staff - in one case, a member of staff was finding it difficult to read some of the writing in the folder and called on another to interpret.  At one stage when staff in a ward setting were finding it difficult to interpret the paper record, I was surprised to hear that my time in A&E was not recorded on the IT system in a way that ward staff could access.. I was told 'they're on a different system'.  It is of course important that the medical staff have control of clinically important information, but patients also (depending obviously on the nature of their condition and related capacities) want to be informed, and can, on occasion, usefully supplement the written record.  Also see the point above about the nurse who discharged me from the hospital and who added an additional informal safety net, 'just in case'.

3. Going forward I am anxious that once the catheter is out, I have a chance to help the bladder recover its elasticity and function as it should. I will be discussing this obviously with the consultant/doctor at that consultation.