19.3 Routine Care: Urinary Catheters, Ostomy & Drainage Systems, Chest Tubes & Wound Care
Key Takeaways
- A urinary drainage bag must stay below the level of the bladder; check position, kinks, bag volume, constipation and dehydration before concluding a catheter has blocked.
- Never break the closed urinary drainage system to check flow, and never inflate a catheter balloon before urine returns.
- A healthy stoma is pink or red, moist, and slightly protruding; a dusky, purple, black, or retracted stoma is a surgical emergency, and ileostomies cause high fluid and electrolyte losses.
- Keep a chest drainage system below chest level and never clamp a chest tube in transport, because trapped air can create a tension pneumothorax; a dislodged tube is covered with a three-sided dressing.
- Do not close wounds that are contaminated, more than roughly 6 to 12 hours old, caused by bites or punctures, or that overlie a fracture or foreign body.
19.3 Routine Care: Urinary Catheters, Ostomy & Drainage Systems, Chest Tubes & Wound Care
CPCF Appendix A minimum entry-to-practice skill #28 — Provide routine care — names six areas: urinary catheters, ostomy drainage systems, non-catheter urinary drainage systems, monitoring chest tubes, tissue and minor wound care, and wound closing. These skills belong to the growing proportion of paramedic work that is interfacility transport, community paramedicine, and treat-and-refer rather than emergency response, and they are examinable content that traditional emergency-focused study skips entirely.
Whether a given PCP performs each of these depends on the provincial regulator and the employer's directive; the knowledge is required regardless.
Urinary Catheters
Why It Matters Prehospitally
A blocked catheter causes pain, agitation, urinary retention, acute kidney injury, and — in a patient with a spinal cord injury at or above T6 — autonomic dysreflexia, a hypertensive emergency (Section 16.4). "Agitated resident at a care home" is frequently a blocked catheter.
Types
| Type | Description |
|---|---|
| Indwelling urethral (Foley) | Retained by a water-filled balloon; the most common |
| Suprapubic | Inserted through the abdominal wall directly into the bladder; used in urethral stricture, trauma, or long-term management |
| Intermittent (in-and-out) | Inserted to drain, then removed; often self-managed by the patient |
| External (condom/sheath) | A non-catheter drainage system — a sheath over the penis connected to a bag, with no urethral instrumentation |
Troubleshooting a Catheter That Is Not Draining
Work through this sequence before concluding the catheter has failed:
- Is the bag below the level of the bladder? Drainage is gravity-dependent; a bag placed on the stretcher beside the patient stops draining and can allow reflux.
- Is the tubing kinked, clamped, or trapped under the patient or a limb?
- Is the bag full?
- Is the patient constipated? A loaded rectum compresses the urethra and the catheter.
- Is the patient dehydrated and simply not producing urine?
- Is the catheter blocked by sediment, a blood clot, or encrustation? Do not force irrigation unless trained, authorized, and equipped.
Never leave a suprapubic or urethral catheter clamped, and never disconnect the closed system to "check" it — breaking the closed drainage system is a leading cause of catheter-associated infection.
Insertion Principles (Where Authorized)
- Strict aseptic technique and full explanation and consent.
- Correct catheter size; a larger catheter is not better and causes trauma and bypassing.
- Use adequate lubricant, ideally with local anaesthetic gel where available.
- Never inflate the balloon until urine returns, confirming the tip is in the bladder and not the urethra. Inflating in the urethra causes serious injury.
- Absolute contraindication: suspected urethral injury — blood at the meatus, perineal or scrotal bruising, a high-riding prostate, or a pelvic fracture. Do not attempt; transport.
- Document the size, the volume in the balloon, the residual volume drained, the urine appearance, and the time.
- Drain large residual volumes with caution per local practice; very rapid decompression of a chronically distended bladder can cause haematuria and hypotension.
Ostomy and Non-Catheter Drainage Systems
An ostomy is a surgically created opening (stoma) diverting bowel or urinary output to the abdominal surface.
| Type | Output | Notes |
|---|---|---|
| Colostomy | Formed or semi-formed stool | Usually left-sided; output less corrosive |
| Ileostomy | Liquid, enzyme-rich output | Right-sided; high fluid and electrolyte losses; output is corrosive to skin |
| Urostomy / ileal conduit | Urine, with mucus | Continuous output; requires a drainage bag at all times |
Assessment and care:
- A healthy stoma is pink or red, moist, and slightly protruding. A stoma that is dusky, purple, black, or retracted indicates ischaemia and is a surgical emergency.
- The stoma itself has no sensory innervation and does not hurt, but the surrounding skin is easily excoriated.
- Do not remove an appliance unnecessarily. If it must be changed, empty rather than replace where possible.
- High-output ileostomy causes dehydration, hypokalaemia, and hypomagnesaemia; a patient with an ileostomy and vomiting or diarrhoea can become profoundly volume-depleted quickly.
- Blockage presents with cramping, absent output, distension, and vomiting — a bowel obstruction requiring transport.
- Bleeding from a stoma may be minor surface trauma or may indicate varices in a patient with portal hypertension.
- Bring the patient's supplies with them; hospitals rarely stock every appliance type, and a patient without their supplies is left in a distressing situation.
- Dignity and privacy are central. Ostomies carry significant stigma; manage them matter-of-factly and out of public view.
Monitoring Chest Tubes
Skill #28 requires the PCP to monitor a chest tube, most often during an interfacility transfer. The competency is vigilance and correct handling, not insertion.
A chest drain removes air, blood, or fluid from the pleural space and re-establishes negative intrapleural pressure. Modern systems combine a collection chamber, a water seal acting as a one-way valve, and a suction control.
The rules:
- Keep the drainage system below the level of the patient's chest at all times. Raising it above the insertion site allows fluid to siphon back into the pleural space.
- Never clamp a chest tube during transport unless specifically instructed and supervised. Clamping a tube that is still draining air converts a simple pneumothorax into a tension pneumothorax.
- Do not empty, tip, or lay the system on its side, which breaks the water seal.
- Secure the tubing so that movement of the patient or stretcher does not pull on it, and avoid dependent loops that trap fluid.
- Record output volume and character before departure and on arrival.
- Watch for bubbling in the water seal. Intermittent bubbling with respiration or cough is normal when air is being evacuated; continuous vigorous bubbling suggests a leak in the system or a large air leak from the lung.
- Watch for tidalling — the fluid level rising and falling with respiration — which indicates the tube is patent and in the pleural space. Its sudden absence suggests a blockage or a re-expanded lung.
If the tube is accidentally pulled out: immediately cover the site with a dressing taped on three sides to act as a flutter valve, assess for tension pneumothorax, give oxygen, and transport urgently. If the system is broken or disconnected, place the tube end in a container of sterile water or saline to re-establish a water seal and transport urgently.
Tissue and Minor Wound Care
Section 13.6 covers wound care in the context of trauma. The routine-care essentials:
- Control bleeding with direct pressure first.
- Assess before dressing — neurovascular and tendon function distal to the wound, depth, contamination, foreign bodies, and mechanism. Document what you found.
- Irrigate with clean water or saline under moderate pressure. Volume and mechanical action reduce infection far more than the choice of antiseptic.
- Do not scrub with antiseptic into the wound bed — it damages tissue and delays healing.
- Dress with a non-adherent layer, absorbent padding, and a securing layer; keep it clean and dry.
- Do not close a wound that is contaminated, more than roughly 6 to 12 hours old, caused by a bite or puncture, over a suspected fracture, or containing a foreign body — closure traps infection.
- Escalate any wound with tendon, nerve, vessel, or joint involvement, or any wound needing exploration.
Wound Closing
Where the PCP is authorized to close minor wounds, the common prehospital and community methods are:
| Method | Best for | Not for |
|---|---|---|
| Adhesive strips (Steri-Strips) | Shallow, clean, low-tension linear lacerations | Wet, hairy, mobile, or high-tension areas |
| Tissue adhesive (skin glue) | Short, clean, low-tension wounds with easily apposed edges | Wounds near the eye, over joints, in hair, on mucosa, or that are contaminated or gaping |
| Hair apposition (scalp) | Short scalp lacerations with adequate hair length | Heavily bleeding or gaping scalp wounds |
Whatever the method: clean and dry the surrounding skin, appose the edges without tension and without inverting them, never glue into the wound bed, and give clear aftercare instructions — keep dry for the stated period, watch for redness, swelling, increasing pain, discharge, or fever, and return if any of those appear. Confirm tetanus status and record it in the handover or referral.
Paramedics are transferring a patient with a chest drain in situ for a pneumothorax. During loading, the drainage system is briefly lifted above the level of the patient's chest, and the crew is considering clamping the tube for the journey. What should they do?
A care home reports that a resident with a long-term indwelling urinary catheter has become agitated over the past two hours. The catheter bag contains 30 mL of urine and is resting on the bed beside the patient. What should the paramedic do first?
A patient presents 8 hours after sustaining a 3 cm laceration to the forearm from a dog bite. The wound is clean-looking and the edges appose easily. Which management is correct?