My first ever patient

I still remember the first patient I examined, diagnosed and treated all by myself. I was a medical student then, not a "real" doctor yet, and I was so pleased and proud that I was trustworthy and knowledgeably enough to see a patient completely on my own!

I took my responsibility seriously. I took a history, including a systems check asking in case there was anything else less obvious that might have been missed. I examined him thoroughly and surprised myself by finding that he had a huge mass in his abdomen! It appeared to be arising from below the pubic bone, and reached up to above his umbilicus. It was tense, hard to the touch, smooth and slightly mobile if I pressed it firmly, which the patient didn't like very much.

In my considered medical opinion, taking into account both history and examination as I had been taught, I decided that it was probably his bladder, most likely blocked due to obstruction from benign protate hypertrophy. I didn't decide this on my own - he told me he was on the waiting list for surgery, but I didn't like to assume anything and decided to hold an open mind on the question of prostatic cancer until I had seen the blood test and biopsy results myself.

I put on my most reassuring manner (I think I was all of 21 years old and looked young for my age) and told him that it would be all right, and that I knew what to do. I was quietly exultant - I did know what to do! History, examination and diagnosis had yielded their fruits to those who paid attention, and treatment was within my grasp.

I turned to ask the nurses to help me set up a tray for a catheterization, only to find it right behind me. "It's a size 8, you'll be fine." The nurse called from her magazine at the desk.

Right. Of course. Size 8, just what I was about to ask for. The only problem being that I had never actually done this myself before. I hesitated between asking her to help me (and maybe give me a few clues in the process) and looking like an idiot in front of her while I fumbled my way around a strange man's penis, or doing it slowly on my own. I opted to do it on my own.

I pulled the curtain around, and the man himself had his eyes closed, so that took care of that. No witnesses, so one less kind of pressure. I pulled on one sterile glove, getting two fingers wedged into one space but I didn't panic. I worked my hand into the other one, and once both were sterile, I adjusted the first hand, silently congratulating myself on remembering that little trick.

I sterilized and draped "the area" making everything appropriately clean and medical looking. This also helped me to distance myself from the fact that I was about to shove a giant rubber tube up this man's penis, and I had never done it before. I braced myself with the thought that someone has to be first...

The anaesthetic cream and lubricant came next. I had a moment of doubt about whether it should go on the catheter itself, or on the penis, but then realized that there was enough to put it everywhere, which I did. Better to be generous with the anaesthetic, just in case.

Moment of truth. I grasped the catheter in my right hand, the penis in my left and brought them together. Or tried to. I had overlooked the fact that lubricant is, well, very slippery. The penis kept slipping out of my left hand, and being right handed, I'm not very dextrous with my left. I almost wondered if I should dig my fingernails in to secure my grip. Fortunately for that gentlemen, the gloves prevented me from trying any such desperate measures.

Finally, I did it, the catheter slid into the meatus and started down the inside of his urethra. Victory was mine! But wait - it caught on something. It was only about ten centimetres inside, so it could not be hitting the back of the bladder wall yet. Besides, there was nothing coming out yet. I tried to remember my anatomy. What is there between the bladder and the meatus in the male that a catheter could get stuck on? And would it be a bad thing for me to push it a bit harder?

I withdrew the catheter a little, and advanced it again. Still stuck. It seemed to be hitting against something kind of rubbery. Then I realized. Of course! This was the enlarged prostate which was blocking him up in the first place, and I was approaching it from the other side. That meant I was at the "neck" of the bladder and almost there! Relief was in sight, for both of us.

Manipulating the catheter, I wiggled and poked and tried different angles. I pulled the penis up and stretched it against the catheter to make the urethra as straight as possible. Finally, I just pushed harder, and it slid through with gentle popping sensation into the bladder. Triumph!

My success was rewarded with a gratifyingly large gush of urine out the other end of the catheter, and the patient groaned. "Hold still just another minute please sir!" I called, while looking for the syringe of water to fill the balloon which would hold the catheter in place. I found it and inflated the balloon. Now, all was secure and I could let go.

Except that there was still one problem. The urine was continuing to gush out, and the plastic tray with the antiseptic and lubricant was clearly not going to hold the more than a litre of liquid which I estimated was contained in this man's bladder. While I was glad that he was feeling better, I had a pressing problem of my own. I was just about to call out for the nurse, when I realized that hanging on the back of the trolley was a urinary bag. Truly, I had never seen such a beautiful sight.

Nonchalantly, as if I had known it was there all along. I grabbed the bag and attached the catheter end. It fit as well as if they were made to go together, and the urine started to flow into the bag just before overflowing the tray.

The bag hung on the bed railing, the disposables disposed of, the gloves very definitely disposed of and with freshly washed hands, I emerged from the cubicle with the empty trolley. The nurse looked up from her magazine. "Get it in? Good. Take the trolley to the pan room."

The nurse went back to her reading and her coffee. The patient was asleep with the sudden relief of pain. And I was a real doctor.

The sense of triumph, the accomplishment of doing what I had already spent four years studying to do, and the excitement of successful problem solving were uppermost in my mind. Naturally, I was glad the man felt better as well, which was the whole point of the exercise, but the hospital would have made sure he was treated. If I had not managed, someone else would have and he was never in any real danger. The one who was most affected by this event was myself. He didn't care who put the catheter in, but I had done it! Floating on a cloud of euphoria, I drifted off to find myself a bathroom...

Of course, in retrospect the patient was "well known to the unit" as the saying goes, meaning that he came through often enough that everyone in the department knew what his condition was and what he needed. The triage nurse at the desk knew that his state was so completely obvious that even a half-blind and completely stupid medical student could be trusted to get it right. But I didn't know all that then.

The thrill of treating people and seeing them get better before my eyes has never left me. That is my drug, my high, the adrenaline rush I live for which keeps me working as a doctor even now, regardless of how ungrateful people sometimes can be, regardless of the hours, the pay, the lack of facilities in the public health system. It is this thrill which addicted me with that very first taste, which I continue to crave daily.

Funny how "helping people" sounds so mundane, prosaic, dorky even. "I want to help people" is the cliche that every would-be medical student trots out in the application interviews. Little do they realize what a relentlessly driving force that want can become as it is reinforced with the heady buzz of every success. That need which is only satisfied by the "click" of a dislocated shoulder sliding back into place, a stone successfully removed from an ear, and yes, the sweet sound of 1.4 litres of urine gushing into a plastic bag.