Thursday, 7 April 2011

Acute Urinary Retention

Initial running title: Anuria during Umrah

I will just relate to you a story of one male jemaah who travelled with us last year to perform Umrah but disaster struck him while we were in flight.

The flight from KLIA to Jeddah was a long one. As jemaah, we had to be physically and mentally prepared. We all sat in a big chartered airplane, feeling quite happy. While everyone was enjoying the trip, somewhere above India, trouble started brewing near where we sat. One male jemaah was having problem sitting down. He seemed unable to talk nor sit. I took a look at him and said to my husband to see if he needed help. At first I thought he had a heart attack but in the case of a heart attack, a patient would fall to the floor in pain. He was just standing there and leaning in pain....nobody knew what was wrong with him. Nobody knew the lady next to him was his wife! Since I wasn't easy watching him in pain, we called the cabin staff. The cabin staff came and took him away. Then a while later they came back and raised a frantic search for a doctor! Nobody budged! I was frozen stiff and I too almost passed out! Since nobody dared, a kind homeopathic doctor offered to help and went to attend to him. He brought along his bag of homeopathic medicines. They had taken the man who was in pain to a more spacious area where there were less passengers. The man in pain didn't return to his seat for which I too got upset should something terrible happen to him. The cabin staff were running back and forth from where we were seated to wherever the sick man was seated. I became very uneasy because I didn't know what was the cause of all the commotion on board. My husband went to enquire. The cabin crew came back to us and asked, a big question which I least expected - could I make this sick man urinate!!!! LOL. The problem this man had was he could not urinate, for which urine had accumulated and filled his bladder and now when his bladder was full, he could not urinate and was in great pain! I didn't know how to react - to laugh or to cry!!!!! Then they asked me, could I insert a tube for him!!!!! I said not without anesthesia cos inserting a tube as is would cause more damage. I wasn't willing to try anything as I simply did not expect something like this to happen, not when I was flying with my family, and of all times, on an Umrah trip! Because I could not help him and nobody else in that big airplane could, I thought to explain it here so readers can benefit. After I told the cabin crew, the ustaz and everyone who waited on me I wasn't inserting the catheter for this man, I gave them instructions to radio over to Jeddah to prepare an ambulance to take him to the nearest health centre and get a catheter in. Should  the sick man develop other problems, we must plan for emergency landing in India - that's an Airbus and no joke, mind you! I think everyone got scared and fell back on doa for this sick man who could not urinate and was in severe pain. We had flown so many hours by the time we reached Jeddah. Ustaz had asked me if the man was going to make it alive. How do you suppose I am to answer a question like that? I said to ustaz, we reassess when we reach Jeddah.

When we arrived in Jeddah, we were packed into a bus and a white Harrier rushed the sick man to the nearest health centre near a marketplace that had a mosque.  I had given instructions for a catheter to be inserted and that was to be communicated to the doctor, best in Arabic! LOL. Meanwhile I waited outside near the mosque. When the sick man eventually came out, he was smiling! His urine had been drained and he was no longer in pain. A catheter made it possible. Phew! Since he was alright, we headed for Madinah, another 8 hours bus drive in the warm night.

When we reached Madinah, this apparently healthy man was ok so I didn't bother to check on him. Somehow around lunch  the following day, I was called again and this time it was the same man and the same problem. He had pulled out the catheter and could not urinate and was in great pain! Again we had to rush him to a health centre and get a catheter in. We told him, "You pull this catheter out, we leave you in the desert and you can die there"

I was a bit furious that this sick man did not heed our advice. Why? Why did he not heed our advice? Why was he creating so much problem for me and our group? Didn't he get a check-up done before coming on this trip? What was his medical history like? I thought hard about what were the reasons he avoided a check-up and why he never told anyone of his medical problems. Was he aware of pains associated with urine distention? Was he aware of his own medical problems? When he was alone I went up to ask him. I asked for his age and he was in his early 60s. He explained that the catheter was always getting in the way. He had pulled out the catheter even before we left KLIA.

Before we left for Makkah, he wore the ihram but had removed the catheter.  When performing tawaf, he said it was better without the catheter. Then I said to him if he pulled it out and expect to know how to re-insert the catheter alone by himself that was fine. The problem was when he tried re-inserting the catheter alone by himself, he bled profusely. I told him that he bled because he was not doing things right. After a lot of advice he was convinced he did the wrong thing (pull out the catheter and re-inserting).

I hope those of you who are  doctors to take note that anuria is common among elderly males even among jemaah Umrah, and to be prepared to rapidly assist if you have been trained. Whether the affected person can last 8 hours or not is not for us to predict but what can possibly happen is the urea can build up  in 8 hours and azotemia may set in for which the person becomes very high risk and death is a possible outcome. Giving coffee and lots of plain water on board whilst in flight will not alleviate the problem and cabin crew must know. Only a catheter is all that is needed. - FAR


mtahir said...

Interesting story. It is better to refer to this malady as acute urinary retention, since there is urine production, it just can't come out. Its the most common urologic emergency and occurs most frequently in men over 60 and is often the result of prostate enlargement.
The preferred method of dealing with such a situation is catheterisation as pointed out by Prof Faridah. However in the absence of doctors, nurses or other suitably qualified personnel, it is better not to "manhandle" the patient. It can wait till the plane lands. But if there is sever distress, bladder distension can be temporarily relieved by needle aspiration - by poking an injection needle into the lower abdomen just above the pubic symphysis. Just watch out for the jet. (Refernces available on request.)

Faridah said...

Thanks for your comments. It wasn't acute as he had the tube inserted quite some time even prior to departure, long before Umrah. It was only at the time of Umrah flight he wanted the tube removed and probably thought he could just re-insert as he pleased. The fact that he had pampers in his carry-on luggage proved that he was prepared but hadn't expected re-insertion would be difficult. I wanted to just drain his urine for him by poking a needle through but that will need a sterile needle and an alcohol swab. The fact that he was in severe pain just threw me off and I decided not to even try. The jet is one thing. Not knowing the male anatomy perfectly as well as exactly where to push it the needle is even worse!

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