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April, 2004

Clinical Story of the Month

An Unavoidable Void


The Fall

It was a Friday evening like many others when the group of five nuns from the 9th Rosary Congregation was taking its after-dinner stroll. Fall had finally arrived in piping-hot Texas, and their pace had picked up, energized by a cooler breeze after the sunset. Sister Rosa was telling a funny story she had heard from one of her students that morning, and the group was laughing to tears. Then it happened. Sister Anna tripped and fell, so suddenly, that she was unable to stop her fall with her hands or knees. Instead, she fell flat on her abdomen and so very hard, that an excruciating pain rushed all through her body and into her back. And there she stayed for a few minutes, like paralyzed, not even daring to lift her head. It took all four of the other sisters to slowly and gently pick her up and check her for injuries. But she was unable to stand or walk, so they dialed 911, and this is how she saw the inside of an ambulance for the first time in her life.

Secured to a gurney, she was driven to the nearest hospital emergency room, only one sister allowed by her side. The pain was relentless, and soon an enlarging blue spot was forming right below her navel.

The emergency room doctor asked for a urine specimen, but no matter how hard Sister Anna tried, no urine would come out, so that after a couple of hours, it was finally obtained through a catheter. Bright red urine flowed into the container, confirming the existence of an inner injury. Many hours and multiple tests later, the diagnosis was delivered as "a contusion of the bladder." The plan was to keep Sister Anna under observation until she would be able to urinate again, and then discharge her with a close follow up. But the night passed and the morning came, and no matter how hard Sister Anna tried, not a drop of urine ever came out.

With great regret, the emergency room doctor had to finally send her home with instructions and supplies to catheterize herself every four hours, or more often if she felt an urge. But Sister Anna never felt an urge again, her bladder had stopped signaling to her; the nerves of the bladder, unfortunately, had been crushed.

The Struggle

Follow up visits to the urologist became increasingly disappointing; "itís just a matter of time," he would say, "probably a few more weeks and your nerve activity will return, so that your bladder muscles can contract again for you to void on your own." But the weeks passed and nothing changed. Sister Anna had by then become an expert in using her catheter, but being an active woman who traveled frequently, having to carry with her a stack of disposable catheters and finding a place to insert them under sterile conditions, was often frustrating and sometimes impossible. Many teaching engagements had to simply be cancelled or postponed indefinitely.

Six months after her injury, she happened to have dinner with a parishioner, who was one of my patients. "Why donít you try acupuncture, Sister Anna?", she asked "Acupuncture?", she looked at her perplexed. "Acupuncture for a bladder injury?" "Yes, why not?", my patient answered. "Call up the office and check with the doctor, she will tell you if she can help or not." "OK," Sister Anna became pensive and quiet. We heard from her early the next morning and I saw her three days later.

A Novel Approach

She was a lovely woman, with apple red cheeks like a farmer, and that content caring smile of those who serve others. "Do you think you can help me doctor?" I was pretty sure I could, and so I told her acupuncture was an excellent approach for nerve injuries, as long as the nerve had not been cut. I inserted a set of acupuncture needles, following a particular design aimed at stimulating the function of the bladder.

"I donít know how fast you will respond," I warned, "but just in case," I continued, as I placed a waterproof pad under her, "I want you to feel free to urinate if you have to." I put on the "Water CD" for her, a composition of creeks and waterfall sounds, in order to further stimulate her nervous system. We set a timer for 25 minutes, after which the needles would be removed. We both looked expectantly at her pad which, to our disappointment, was still dry. "Now I want you to go to the bathroom and sit on the commode, like you used to. Just sit there a little and letís see what happens. We will put your "Water CD" on with you in the bathroom, so that you have the extra help you need."

I went on to see other patients, and once I came out she was waiting for me, with a big, bright smile on her face. She walked towards me, her arms open and hugged me dearly, "Thank you, thank you," she repeated, "I did it, I did it, and thank you again Dr. Stemmler, this is a miracle!" We all rejoiced in her accomplishment, and I gave her a Chinese herbal preparation and instructions to carry out at home, until her next visit a week later. "You see, your bladder needs to be retrained now," I explained, "it may have become used to being emptied without doing any work. I want you to sit on the commode every hour while awake, and see what happens. Try not to use the catheter unless nothing comes out in eight hours or so. Should this happen, call me. In fact, call me with any questions, any time. You may take the "Water CD" home with you and just bring it back next week. You will do fine."

The following week she returned beaming with excitement. "Iíve done great! I did not have to use my catheter at all!"

Just In Case?

A week later she again raved about her ongoing success, but on two occasions, she confessed, she still did use the catheter. She then explained that she had used it once, before going to a long-lasting public event, where she would not have been able to catheterize herself if the need arose. The second instance was one evening, when she felt more secure using the catheter before bedtime, "in case I needed it." I realized that her success had been so fast and so unexpected, that she was beginning to have doubts about how effectively she was able to clear her bodyís toxins, by just urinating on her own.

During the six months she was unable to void, she and her catheter had become one, a sort of love-hate relationship. For those six months that catheter was her life-saving device. Could she be completely sure that her newly resumed trips to the bathroom were equally effective as her catheter had been? We talked, and I suggested a strategy to overcome her addiction to the catheter, as well as the lack of confidence in herself. The plan was to check a urinalysis that day to evaluate the quality of her urine, while also drawing a blood specimen to check her kidney functions and other related values in her serum. She was also instructed to measure all her urine at home, so that we would both be satisfied with her 24-hour urine output Ė she agreed.

Faith & Miracles

A week later she came in bouncing and happier than ever. "Dr. Stemmler!" she hugged me again "you just knew what was going on inside me and picked the right approach. When I got home that evening I thought to myself ĎWhat am I doing? Why go through all the trouble of measuring every drop I put out? I will just have to trust myself as capable of functioning the way I should.í So I put all my catheters away, and I have been urinating just fine, as I always did, and I didnít need to get up at night either, just as I never did before. Dr. Stemmler, I donít think I need any more treatments!" I agreed. Her urine was perfectly normal, and so was her kidney function; it was time for her to return to her busy, normal life.

Before she left, Sister Anna approached me one more time and whispered in my ear: "You know doctor, I am telling my students and my other sisters, miracles are not necessarily unusual and extraordinary events; miracles occur every day. This is a big miracle that was granted through you. Quite a big miracle, I should say!"

Summer Thoughts by Two Japanese Poets

A petal shower
of mountain roses,
and the sound of the rapids.
Matsuo Basho (1644-1694)

In the summer rain
the path
has disappeared.
Yosa Buson (1716-1783)

Christina Stemmler, M.D.

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