This cardiac radiology case involves a female patient who suffered from acid reflux and had used heartburn medication in the past, was admitted into the ER and diagnosed with a small bowel obstruction in Arizona. She had a nasogastric tube placed for decompression of her stomach and placement was checked by stethoscope. Following the placement, an x-ray was taken which showed that the feeding tube seemed to extend into the patient’s lungs. This was discussed with the patient’s nurse. The patient was then transported to the interventional radiology department in order to have the nasogastric tube placed again. While in the interventional radiology department a code blue was called. After the procedure was completed, the patient was noted to look unwell, and then became unresponsive. The patient suffered a cardiac arrest following the placement of the new tube, and eventually passed away.
Question(s) For Expert Witness
- 1. Do you routinely care for patients like the one described above?
- 2. Have you ever published or lectured on this subject?
- 3. What is the nursing protocol to place and use a nasogastric tube?
Expert Witness Response E-007898
As a Director of Nursing and a staff nurse in the Emergency Department, I have worked with placement of nasogastric tubes many times. After placing the tube, you always confirm placement by inserting air into the tube while simultaneously listening with a stethoscope for a sound of air over the epigastric region. The gold standard in the field is to follow this up with an x-ray to confirm placement. Some ERs also use ultrasound to confirm placement. The American Nurses Association has a position paper on this subject for critical care nurses can refer to. Here is one protocol described in greater detail:
- Measure tube from tip of nose to subxyphoid process.
- Gather a cup of water with a straw
- Wash hands and don gloves
- Check the physician order for size of tube and amount of suction to be applied.
- Prep the nose for the later taping the tube in place.
- Insert the tube while asking the patient to swallow water via the straw.
- Stop at 35mm to make sure your not in the bronchus (via chest x-ray). When confirmed continue into the stomach. Check placement by inserting air into the stomach and confirm with an abdominal x-ray.
Expert Witness Response E-075592
I have worked in the ICU for almost 10 years. The protocol is to verify placement with an X-ray before instilling anything through it and to note and record it’s length at the exit site. A small air bolus can then be used, together with length at exit site every shift and as needed. Additional radiologic verification is necessary whenever there is a doubt in it’s placement.