Back in August, when I was still mystified about how an NG (nasogastric) tube works (which is rather shameful, because it only has two ends, and one extra piece in the middle, and is used in nearly 50% of surgical patients), I used to watch my chief checking fanatically on the NG tubes of patients on a particular unit. I couldn’t understand why she was always handling the thing whenever she walked by, and often holding it up to her ear.
Now I know that one end of the tube goes down the patient’s nose into the stomach (ok, I knew that a long time ago), and the other end should be connected to a cannister on the wall, which should be connected to a mechanical suction device, which should be turned to on and set to medium suction. The purpose is to remove the saliva and gastric secretions which accumulate in the stomachs of people whose bowels aren’t working properly, for various reasons. If the NG does not work correctly, there are several problems: 1) you stuck an uncomfortable tube down someone’s nose and throat for no purpose, and exposed them to the risk of developing sinusitis unnecessarily, since they don’t benefit from a nonfunctioning NG; 2) they can become quite uncomfortable, since one of the main functions of an NG is to relieve/prevent nausea; 3) most importantly, they are at high risk for aspiration, since when an elderly person vomits they can aspirate and get pneumonia, and now that you have an NG tube holding their epiglottis open, and undrained fluid backing up in the stomach, you’ve actually made things worse than if the NG wasn’t there.
The part of the NG that used to puzzle me is the sump section (medical students may find this neatly diagrammed in Surgical Recall, the best book ever for students on a surgery rotation), which is a small blue tube added to the main one halfway along, whose purpose is to allow air to be drawn down it and into the stomach, thus protecting the lining of the stomach from being vacuumed against the end of the tube. While this is open, you can put the tube to continuous drainage without fear of causing ulcers or bleeding. If, however, it is not working, you could be harming the patient yet again. When it is functional, it will often give off a continuous low whistle – which is what my chief used to listen for.
The reason she listened fanatically on that floor in particular I have now discovered. The nurses on that floor, from the most junior, up to their supervisor, have no clue what to do with an NG tube. They will clamp it contrary to orders, they will connect it to a thing on the wall which is not suction, they will connect it but leave the suction turned off, they will turn the suction on but so low that it does no good, or they will even – this is what happened today – manage to disassemble and then reassemble the sump section so that everything is running backwards, and is useless. What puzzles me is that all of these things take some effort. Every morning we walk through and make sure that the pieces are in order and connected. If they would not touch it, the laws of entropy suggest that the pieces would stay where we put them. So how, every day, we find yet another rearrangement which does the patient no good, and actually increases his risk of aspiration, is a mystery to me.
Admittedly it’s not a surgical floor, and has other specialties which (I hope) they are good at. But when my chief walked in, an hour after I had seen everything in order, and found this latest hopeless variation on what not to do with an NG tube, I was humiliated enough to take the nurse aside, after we had showed several nurses and the supervisor what to do with an NG, and make a few forceful comments on their disgraceful ignorance (I didn’t use those words – or maybe I did say disgraceful). This is the same floor, and the same nurse, who have done other disgusting, neglectful, and foolish things to my same patients, because they are too confused, or perhaps too lazy, to take proper care of a surgical patient. I think I should honestly beg the nursing supervisor of the surgical floor – who keeps all the surgeons in line quite handily – to go and give them a lecture on which end is up, and the dangers of neglecting an NG. That, and/or write an incident report on some previous events; which I hate to do, but it’s getting to be too much. (The best part is that I know surgical residents have been fighting this losing battle for years, since in retrospect I also remember my chief inviting the nurses into the room to ask what they had done to the NG, and demonstrating how to fix it and troubleshoot a few simple things. As I said, it only has two ends and one sump, and if not touched, should stay as it was. . .)
In charity, I suppose, all the holes and devices on surgery patients can be quite mystifying to the uninitiated, and there is the – sometimes warranted – fear that if you touch something you’re not familiar with, you could mess it up quite badly. Also, there are medical issues (like any kind of cardiac arrhythmia) which are quite out of the experience of the surgical nurses, and which they dislike as much as the medical nurses dislike our drains and wound dressings. But some of the recent events are truly disgraceful.