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.
Cut On The Dotted Line 
April 4, 2008 at 6:23 pm
The most recent incident report I’ve had to write was because a disgracefully incompetent nurse told my patient with asymptomatic bradycardia that if he fell asleep he would die. It’s tough to maintain equanimity when discussing that sort of thing.
April 5, 2008 at 7:38 am
I am a nurse. I apologize for the obvious failure of my colleagues to correctly manage an NG tube. However, as I read this post, I was disturbed by the “tone” with which the problem was discussed. Nurses were described in the following manner: “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.” Are you talking about ONE nurse or about NURSES in general? Even if you are talking about ONE nurse, I take exception to use of insulting language. If you are using that statement to describe nurses in general then you are demeaning my profession. As a nurse, I take great pride in what I do and I do it well. As a profession, nursing takes responsibility and is accountable for nursing practice. Problems such as you encountered with the NG tube should be “easy” to solve between two professions, medicine and nursing, without stooping to derogatory speech.
April 5, 2008 at 7:42 am
Nathan – That is horrible, and worse than anything I’ve encountered so far.
Vonnie – Three nurses, if you want to be precise. I would never talk about nurses in general that way. I think my patient was just unlucky enough to be on the section of the hallway that belongs to the three least competent nurses on a floor which, as a whole, is much better at taking care of medical than of surgical problems.
Someday, I ought to clarify this in the original post rather than in comments. 🙂 I love surgical and ICU nurses, and I owe them my life (or my patients’) on multiple occasions. It’s just the medical nurses who seem to think that if they don’t look at the wounds, they won’t matter, who really bother me.
April 5, 2008 at 7:56 am
Thanks for the clarification, Dr. Alice. As a nurse, I do my best to identify and correct nursing practice problems; I also love to teach novice nurses how to correctly manage patients. (And, I love the outcomes of correctly cared-for patient.) I enjoy reading your blog.
April 13, 2008 at 2:52 am
Alice,
I don’t know how things work at YOUR hospital, but the concept behind incident reports is SUPPOSED to be that they are to help the quality improvement folks find system flaws so they can be corrected.
When you have a recurrent issue with a relatively simple piece of equipment, and you have unsuccessfully attempted to educate those responsible for keeping an eye on it, it is time to write an incident report. Then perhaps the hospital education department, or the nurse manager of the unit, will make sure that those who are not managing the equipment properly on an ongoing basis receive some further education.
I’ve tried to picture just how you can manage to put an NG and suction together incorrectly and simply cannot conceive how that is managed. I know that I went to nursing school in a different era and we use the things frequently here, but still, it’s a SIMPLE piece of equipment.
May 27, 2009 at 4:30 pm
I know it can be time-consuming to update your blog but thank you for keeping me informed and entertained!
September 22, 2010 at 3:53 pm
Dear Dr.Alice,
Based on the tone of your voice, it sounds to me like you have very little regard for nursing in general!
If you had any kind of regard for our practice and the safety of your patients, you would not let these nurses fall through the cracks. Why don’t you bring these issues to the Nurse Educator or Quality Representative for the hospital.
I believe you catch more flies with honey and if you happen to be one of those surgical doctors with a chip on your shoulder(like you are GOD), then I can only imagine how the staff feels around you.
I don’t know if you are the attending, but if you are, you need to attend a communication and conflict management course.
March 25, 2013 at 12:12 pm
As a great PICU RN I was also really disturbed by the tone of this blog. I have encountered more than one ‘incompetent’ and ‘lazy’ resident that I’ve had to teach about NG tubes, suctioning and the difference between a salem sump and corepak. The cool thing about medicine is that there is A LOT to learn and it is constantly changing. The great thing about having a boyfriend who is a doctor is realizing how little MD’s realize about the nursing process and how little RN’s realize about the MD process. It’s completely different, so instead of assuming the worst, realize that the education process is completely different and that a lot of the time nurses save the ass of physicians. It’s a two way street and it’s MD’s who think as you expressed above that create a greater whole in the divide. Just because you went to med school does NOT mean you are better than me at patient care.
July 6, 2013 at 5:32 pm
I agree with your statement. I work with 2nd year residents whom work with 30 year veteran nurses and DO NOT know the difference between an NGT and a Salem Sump tube and actually ‘write the RN up because of their ‘lack of knowledge’. Taping with 2 inch nylon tape a foley around a gentleman’s leg which could cause a ‘skin tear’. Because they gave Dilaudid and then IV Benedryl to an 84yr old patient (who was drug nieve)causing a drug reaction in stead of ordering Haldol in the geriatric population which would have been the drug of choice!!! Of course I had the nerve to question it! Then because of the change in mentation, had to have an emergent CT of the brain to R/O a CVA. Then when ASA was to be given if approved by the neurologist from troponins from 12 hrs previous, wrote the nurse up stating that she endangered the patient by ‘not giving the baby asa for 4hrs, but the order was written at 1630, and given before 1800, along with the ‘ARB’ ordered, patient already on having been on an IV beta-blocker, and the documentation by the resident was untrue. Because of their ‘lack of knowledge and experience’ and feeling intimidated and the clincher— is the nurse may loose her job because of the falsified records. Residents are intimidated by Nurses at times that have learned by Great surgeons that have been Great teachers through the years, and have taught us well, Not demeaned us, but worked with us as an integral part of the TEAM!!!
March 25, 2013 at 12:13 pm
Oh DUDE and you’re a CHRISTIAN? wow. Maybe you should practice non-judgement and compassion and assume the best of your nurses.
July 6, 2013 at 5:43 pm
I have learned over the last 10 of 30 years, that everyone is out for themselves. There is no ‘justice in the Justice system’, the Physicians and Nurses will stab you in the back, The institutions say ‘Patients’ First, but it has become all about the Computers in REALITY! If it is documented it is DONE, whether it is done or Not. Read Dr. Phil. The Rules have ALL Changed. No More Mr. Nice Guy. Look at the young nurses today. Their assessments are done in record time. They have time to play on the internet and cellphones. The old nurses still comfort and console patients and families. Physicians are retiring early. Medicine and Nursing has definitely changed. Compassion and empathy are OUT. Follow the Money Trail. Look at the documentation. Spent this much time with… Labs…Cut and Paste…I/O…Cut/Paste… History…Cut and Paste…
May 10, 2015 at 12:32 pm
What worried me was the naive assumption that an NG tube was only a dual lumen salem tube & pump. Having spent a little time cutting through the lack of clear information on single lumen tubes (from manufacturers to doctors) I can understand how busy nurses could do something wrong. Clear obvious instruction (with reasons) is always necessary. Junior doctors are the worst for this.
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