Consulting other services for "basic" skills

[armybound]

We had a very unfortunate case recently where a patient died of aspiration after an attempted NG tube placement. The events leading up to the aspiration caused a lot of discussion at our M&M.

The patient clearly had an ileus and was vomiting and needed an NG tube. We asked the nurse to try, then the charge nurse when that wasn't successful. At this point we considered consulting general surgery for the NG tube placement, as none of us (urology residents) had any significant experience placing NG tubes. Basically we thought if an experienced nurse couldn't get it, those of us with 0-1 NG tube attempts ever wouldn't be able to get it either.

We mentioned this to our staff at M&M and got ripped apart. How could we be surgeons and not place NG tubes? How did we get through intern year without doing this? "When I was a resident...."

Bottom line, it's not something we do. I wouldn't expect a general surgeon or any other surgical specialty to be able to place a difficult Foley if a couple of experienced nurses have tried and failed. I wouldn't even expect a resident to try, as I assume they're not placing many Foleys, even in the OR.

Just curious of other thoughts on these sorts of situations.

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[ram006]

We had a very unfortunate case recently where a patient died of aspiration after an attempted NG tube placement. The events leading up to the aspiration caused a lot of discussion at our M&M.

The patient clearly had an ileus and was vomiting and needed an NG tube. We asked the nurse to try, then the charge nurse when that wasn't successful. At this point we considered consulting general surgery for the NG tube placement, as none of us (urology residents) had any significant experience placing NG tubes. Basically we thought if an experienced nurse couldn't get it, those of us with 0-1 NG tube attempts ever wouldn't be able to get it either.

We mentioned this to our staff at M&M and got ripped apart. How could we be surgeons and not place NG tubes? How did we get through intern year without doing this? "When I was a resident...."

Bottom line, it's not something we do. I wouldn't expect a general surgeon or any other surgical specialty to be able to place a difficult Foley if a couple of experienced nurses have tried and failed. I wouldn't even expect a resident to try, as I assume they're not placing many Foleys, even in the OR.

Just curious of other thoughts on these sorts of situations.

Unless he had some pretty significant facial trauma, I would tend to agree with your faculty.

There are some things all doctors should be able to do particularly those who perform intra-abdominal surgery.

Nurses aren't allowed to place NG tubes because they're specially trained, they're allowed to do them because they require minimal skill. I suppose if you've really had zero experience (which is incredibly hard to believe, btw), asking for help is always reasonable. The more concerning thing, in my opinion, is you had a patient that needed help and you didn't even try... hope your hospital has a good lawyer.

 

[doc05]

Here's some advice: don't discuss m&m cases on the internet.

 

[armybound]

Here's some advice: don't discuss m&m cases on the internet.

"I had a patient who aspirated and died" is too much information to mention on a board like this? Interesting.

 

[armybound]

I suppose if you've really had zero experience (which is incredibly hard to believe, btw)

Of the 5 residents present, one resident had placed 1 NG tube and one resident had placed around 4. The others had never personally placed one. This represents PGY 2, 3, 4, 5, and 5.

 

[ram006]

"I had a patient who aspirated and died" is too much information to mention on a board like this? Interesting.

Before this devolves, there is an actual lesson to be learned.

There are a lot of people that wear white coats in the hospital. NPs, PAs, PharmDs, med students, etc. and they all have an opinion on how THEY should manage THEIR patient. That is, until s$%# hits the fan. That's when they become YOUR patient.

Deferring to a nurse's expertise will never end well. You're a surgeon.

I'll fast forward to when this goes to litigation for you.

"Doctor, my patient went to you for a RPLND. Is post operative ileus a common issue following intra-abdominal surgery? Oh it is? Yet you are incapable of placing an NG tube-- the standard treatment for an ileus? So why did my patient trust you with their life to perform a complex intra-abdominal surgery when you can't even perform a basic bedside procedure? Are you incompetent? Are you unsafe?"

Harsh scenario but I promise you it's not far off...

 

[armybound]

Before this devolves, there is an actual lesson to be learned.

There are a lot of people that wear white coats in the hospital. NPs, PAs, PharmDs, med students, etc. and they all have an opinion on how THEY should manage THEIR patient. That is, until s$%# hits the fan. That's when they become YOUR patient.

Deferring to a nurse's expertise will never end well. You're a surgeon.

I'll fast forward to when this goes to litigation for you.

"Doctor, my patient went to you for a RPLND. Is post operative ileus a common issue following intra-abdominal surgery? Oh it is? Yet you are incapable of placing an NG tube-- the standard treatment for an ileus? So why did my patient trust you with their life to perform a complex intra-abdominal surgery when you can't even perform a basic bedside procedure? Are you incompetent? Are you unsafe?"

Harsh scenario but I promise you it's not far off...

And yet, in this case and what's clearly written above, after the nurses attempted NG tube placement we "considered" consulting other services. The further details of the case are not discussed here. So I appreciate your concern regarding the legal implications of our lack of experience with NG tube placement, but without further details of the case I'm not sure we should focus on how "I'm" going to be getting sued for this.

But I guess if that's what we're going to focus on, shouldn't it make more sense that we consult another service that has more experience with placing NG tubes? At what point in my career should I be perfecting skills that I never learned but "should have" learned as a general surgery intern, like chest tube placement, subclavian line placement, etc? Pseudoaneurysms are not uncommon after partial nephrectomies, should I learn how to embolize them, or should I consult IR?

 

[ram006]

And yet, in this case and what's clearly written above, after the nurses attempted NG tube placement we "considered" consulting other services. The further details of the case are not discussed here. So I appreciate your concern regarding the legal implications of our lack of experience with NG tube placement, but without further details of the case I'm not sure we should focus on how "I'm" going to be getting sued for this.

But I guess if that's what we're going to focus on, shouldn't it make more sense that we consult another service that has more experience with placing NG tubes? At what point in my career should I be perfecting skills that I never learned but "should have" learned as a general surgery intern, like chest tube placement, subclavian line placement, etc? Pseudoaneurysms are not uncommon after partial nephrectomies, should I learn how to embolize them, or should I consult IR?

Really? Comparing post op ileus to a pseudoaneurysm?

Well, that went in one ear and out the other but I'll bite since I'm off this weekend.

What would make the most sense is that someone who routinely performs intra-abdominal surgery show some insight, take some responsibility for their mistake and learn how to place an NG tube so that another patient doesn't die on the floor from lack of MS4 level medical care.

I'll ask, but I already know the answer, have made even the slightest attempt to learn how to put down an NG?

You'll feel even worse about the situation when you learn how easy it is. Or you won't judging by how you've rationalized this out in your head.

 

[Wordead]

Yeah dude I expect even the orthos to try putting their own NGs in. I am extremely confused how an entire urology service has never placed one considering how many big abdominal cases you guys do plus you rotate through general surgery still. I don't think it's appropriate to consult other services for this stuff - it's a skill deficiency that you guys should be actively trying to fix. I think most of my M4 students know how to do it. To me, that's akin to calling a consult for like chest pain without having a basic EKG/cxr/etc done.

We get calls (ENT) to put them in under "direct visualization" and unless there's a skull base fracture or a mass or something the answer is no. My answer is I'll come teach you guys how to do it but I want your entire team down to the attending there because it's embarrassing that you can't do this.

 

[CTFellowMD]

Bottom line, it's not something we do. I wouldn't expect a general surgeon or any other surgical specialty to be able to place a difficult Foley if a couple of experienced nurses have tried and failed. I wouldn't even expect a resident to try, as I assume they're not placing many Foleys, even in the OR.

Just curious of other thoughts on these sorts of situations.

I actually don’t agree with your rationale that it just isn’t something you do.

NGT placement in a patient without trauma or some sort of deformity is a basic surgical skill that all surgeons should know how to do. As a chief in my ol gen surg years, I expected the rotating uro interns to become adept at it. If the uro team ever consulted me for ngt placement, I would not be very kind, since we made sure they all learned how to do it at some point in their training. If they still didn’t feel comfortable, I’d go supervise their chief doing it, since again, it is a basic skill.

It goes the other direction too. When I rotated as an intern on uro, I had to learn some “complicated” foley techniques, including coudets, CBI, etc.

If you are rotating on these other surgical services and not learning the basic skills of that speciality, then the rotation is a waste and your program is letting you down.

 

[armybound]

Really? Comparing post op ileus to a pseudoaneurysm?

Well, that went in one ear and out the other but I'll bite since I'm off this weekend.

What would make the most sense is that someone who routinely performs intra-abdominal surgery show some insight, take some responsibility for their mistake and learn how to place an NG tube so that another patient doesn't die on the floor from lack of MS4 level medical care.

I'll ask, but I already know the answer, have made even the slightest attempt to learn how to put down an NG?

You'll feel even worse about the situation when you learn how easy it is. Or you won't judging by how you've rationalized this out in your head.

Well, the point of what you're asking isn't being missed here - I'm simply trying to redirect the conversation since it has already deviated from my intended discussion and I don't feel it's fruitful to discuss without all of the facts of this particular situation. The additional details of how the aspiration event came about are what I feel shouldn't be discussed on the internet. The patient didn't die because two nurses tried an NG tube and couldn't get it. If you'd rather make this conversation about whether or not a surgeon should know how to place an NG tube, I guess we'll talk about that.

My personal experience with NG tube placement is watching a chief resident place one once. He walked me through the steps. Showed me some tricks he uses to ease the experience. So do I know how to place one? Sure. I know the basics of it. After last month's M&M I even tried one with one of my coresidents. It was ugly and not successful. After the M&M discussion, it seems that most of my coresidents have had a similar experience with never attempting NG tube placement.

My basic question is - if you have people with more experience than you who have attempted an intervention but were unsuccessful, is the most appropriate next step to attempt the procedure yourself even though you have less experience than those who have tried, or do you consult another service?

 

[armybound]

Yeah dude I expect even the orthos to try putting their own NGs in. I am extremely confused how an entire urology service has never placed one considering how many big abdominal cases you guys do plus you rotate through general surgery still. I don't think it's appropriate to consult other services for this stuff - it's a skill deficiency that you guys should be actively trying to fix. I think most of my M4 students know how to do it. To me, that's akin to calling a consult for like chest pain without having a basic EKG/cxr/etc done.

We get calls (ENT) to put them in under "direct visualization" and unless there's a skull base fracture or a mass or something the answer is no. My answer is I'll come teach you guys how to do it but I want your entire team down to the attending there because it's embarrassing that you can't do this.

Similar question for you - at what point should ENT be consulted for this type of thing? We had one recently with a lot of resistance and bleeding. Should we consider it only if the patient's had a history of ENT procedures or what?

We've never consulted ENT for NG tube placement, only general surgery.

I've been consulted by ENT for Foley placement without the physician trying. How often do you all put in Foleys? I probably interact with ENT the least of all other surgical specialties.

 

[CTFellowMD]

Really? Comparing post op ileus to a pseudoaneurysm?

What would make the most sense is that someone who routinely performs intra-abdominal surgery show some insight, take some responsibility for their mistake and learn how to place an NG tube so that another patient doesn't die on the floor from lack of MS4 level medical care.

I'll ask, but I already know the answer, have made even the slightest attempt to learn how to put down an NGT?

This.

Yeah dude I expect even the orthos to try putting their own NGs in.

And this.

We get calls (ENT) to put them in under "direct visualization" and unless there's a skull base fracture or a mass or something the answer is no. My answer is I'll come teach you guys how to do it but I want your entire team down to the attending there because it's embarrassing that you can't do this.

Oh, and especially this.

As we are all saying, it is a basic surgical skill. You are performing large operations with ileus as a common complication. You should be able to at least initially manage it. If someone isn’t teaching you how to put in NGT, you should be demanding the training, not trying to get people on a forum agree with you that your faculty are wrong.

 

[ram006]

Similar question for you - at what point should ENT be consulted for this type of thing? We had one recently with a lot of resistance and bleeding. Should we consider it only if the patient's had a history of ENT procedures or what?

We've never consulted ENT for NG tube placement, only general surgery.

I've been consulted by ENT for Foley placement without the physician trying. How often do you all put in Foleys? I probably interact with ENT the least of all other surgical specialties.

I don't think anyone is saying you should cowboy up and do things you're not comfortable with. I think people are saying you should be concerned that you don't feel comfortable managing a post op-ileus as a surgeon that operates in the abdomen.

 

[armybound]

I actually don’t agree with your rationale that it just isn’t something you do.

NGT placement in a patient without trauma or some sort of deformity is a basic surgical skill that all surgeons should know how to do. As a chief in my ol gen surg years, I expected the rotating uro interns to become adept at it. If the uro team ever consulted me for ngt placement, I would not be very kind, since we made sure they all learned how to do it at some point in their training. If they still didn’t feel comfortable, I’d go supervise their chief doing it, since again, it is a basic skill.

It goes the other direction too. When I rotated as an intern on uro, I had to learn some “complicated” foley techniques, including coudets, CBI, etc.

If you are rotating on these other surgical services and not learning the basic skills of that speciality, then the rotation is a waste and your program is letting you down.

I appreciate your input. It's embarrassing but I think important to hear what you all are telling me, and honestly I've never thought of NG tube placement as something I really needed to know. As an intern we spend half of our year on urology and in the SICU. In our SICU rotation we got pretty good at placing A lines and central lines. The rest of the year we got decent at things like wound vac changes, port removals, etc. I honestly believe that in my 6 months of internship not on those other rotations, I only witnesses an NG tube placement once. In general, at my hospital, it's something we order the nurses to do and the vast majority of the time we're successful. We basically view it as a nursing skill, like Foley placement, that got pushed up to general surgery only if nurses weren't successful.

If I had realized that NG tube placement was something that would be expected of urology I would have made a bigger effort to gain experience. I suppose going forward I should try to develop that skill.

 

[Wordead]

Similar question for you - at what point should ENT be consulted for this type of thing? We had one recently with a lot of resistance and bleeding. Should we consider it only if the patient's had a history of ENT procedures or what?

We've never consulted ENT for NG tube placement, only general surgery.

I've been consulted by ENT for Foley placement without the physician trying. How often do you all put in Foleys? I probably interact with ENT the least of all other surgical specialties.

ENT should not be involved unless skull base fracture is present in my opinion. Resistance and bleeding means you're doing something wrong - use some urojet (yes, your foley lidocaine jelly), decongest with some afrin, try the other nose.

It's a 2 way street. If ENT is consulting you without even trying for a basic foley (barring stricture/prostate CA/etc), I'd call that ridiculous too.

 

[CTFellowMD]

I appreciate your input. It's embarrassing but I think important to hear what you all are telling me, and honestly I've never thought of NG tube placement as something I really needed to know. As an intern we spend half of our year on urology and in the SICU. In our SICU rotation we got pretty good at placing A lines and central lines. The rest of the year we got decent at things like wound vac changes, port removals, etc. I honestly believe that in my 6 months of internship not on those other rotations, I only witnesses an NG tube placement once. In general, at my hospital, it's something we order the nurses to do and the vast majority of the time we're successful. We basically view it as a nursing skill, like Foley placement, that got pushed up to general surgery only if nurses weren't successful.

If I had realized that NG tube placement was something that would be expected of urology I would have made a bigger effort to gain experience. I suppose going forward I should try to develop that skill.

I may have come off a bit harsh so I do apologize.

It sounds like the big issue here is that the nurses are doing the tubes, so as a whole the surgery interns aren’t. Out of curiosity, how are the general surgery interns learning how to do them?

 

[armybound]

If someone isn’t teaching you how to put in NGT, you should be demanding the training, not trying to get people on a forum agree with you that your faculty are wrong.

Oh trust me I'm not trying to get anyone to disagree with my faculty. I'm trying to gather opinions. All of the residents were a bit surprised that our faculty expected us to try it since we had such little experience with NG placement. We sort of thought they were coming at it with an outdated perspective, and I was curious what the current perspective is.

I asked a couple of the general surgery residents at my hospital what they thought and it was kind of a mixed response. They're used to getting the consult so I think they understand it. One resident basically said he doesn't care if we consult them to insert it but we should be able to manage it afterward.

 

[armybound]

ENT should not be involved unless skull base fracture is present in my opinion. Resistance and bleeding means you're doing something wrong - use some urojet (yes, your foley lidocaine jelly), decongest with some afrin, try the other nose.

It's a 2 way street. If ENT is consulting you without even trying for a basic foley (barring stricture/prostate CA/etc), I'd call that ridiculous too.

Interesting. Never considered urojet.

I actually have no issue with anyone else not trying a Foley. I get upset if NO ONE tried a Foley, or if I recommend that a nurse try something different (such as a Coude) and they refuse. I have never asked another physician to try a Foley - I assume that if an experienced nurse can't get it, someone who puts in fewer Foleys than an experienced nurse doesn't need to bother trying.

I'm genuinely curious as to experience other specialties have with Foley placement. I imagine in the OR they're almost all placed by the circulator. I don't think I've ever gotten a call from a resident saying "Hey I tried some different things but still can't get this Foley.."

I may have come off a bit harsh so I do apologize.

It sounds like the big issue here is that the nurses are doing the tubes, so as a whole the surgery interns aren’t. Out of curiosity, how are the general surgery interns learning how to do them?

No problem. Well I think beyond the fact that nurses do many of them, the categoricals often get first pick. Like my one chest tube attempt was basically because no categoricals were around. The upper level who gets the consult usually calls a categorical to come do it because they know it's a skill they have to have, whereas a uro intern probably won't ever do one again.

We have had at least 3 post-op pneumothoraces recently that we consulted gen surg for. Your thoughts on chest tubes/pigtails and other surgical specialties being able to place them? It's unfortunately recently been a more common complication of robotic partial nephrectomies than we would like.

 

[Wordead]

Interesting. Never considered urojet.

I actually have no issue with anyone else not trying a Foley. I get upset if NO ONE tried a Foley, or if I recommend that a nurse try something different (such as a Coude) and they refuse. I have never asked another physician to try a Foley - I assume that if an experienced nurse can't get it, someone who puts in fewer Foleys than an experienced nurse doesn't need to bother trying.

I'm genuinely curious as to experience other specialties have with Foley placement. I imagine in the OR they're almost all placed by the circulator. I don't think I've ever gotten a call from a resident saying "Hey I tried some different things but still can't get this Foley.."


No problem. Well I think beyond the fact that nurses do many of them, the categoricals often get first pick. Like my one chest tube attempt was basically because no categoricals were around. The upper level who gets the consult usually calls a categorical to come do it because they know it's a skill they have to have, whereas a uro intern probably won't ever do one again.

We have had at least 3 post-op pneumothoraces recently that we consulted gen surg for. Your thoughts on chest tubes/pigtails and other surgical specialties being able to place them? It's unfortunately recently been a more common complication of robotic partial nephrectomies than we would like.

Chest tubes are rare enough that you might go through med school and residency without ever seeing one if you don't do trauma rotations. And the consequences of a screwed up chest tube are a lot worse (not to say that I haven't seen my share of NG complications).

Pretty much everyone at some point in training should have seen a SBO or someone who can't take PO for whatever reason.

In your OR scenario, I agree there's not much point in the resident trying in that case. But the resident was there, can see what happened - couldn't get it into the meatus, we tried this size, it stops at this length, etc. They tried to troubleshoot it together. It's not "my nurse on the floor who is of variable experience told me he/she couldnt get it, can u do it".

 

[Dr.LeoSpaceman]

I won't rehash what's been said, so I'll only say that I agree with everyone else: NG placement should be a skill posessed by anyone operating in the abdomen.

To answer your other question about consulting another service, I'd say it's only reasonable if you've tried personally and failed. Doesn't matter if you think you won't be successful, as long as you believe you can attempt it safely. You should feel responsible enough to at least try.

You mentioned foley placement, so I'll use that example. I've had to call in urology for a foley a handful of times, and in all of those cases I had already attempted myself. Each if those times it required a cysto or filiform/follow to get it in which is beyond the limit of what I can do safely. But because I'm willing to try the "easy" stuff like a Coudet, I hope I've not only done what's right for the patient but also saved my urology colleagues some annoying calls.

 

[CTFellowMD]

We have had at least 3 post-op pneumothoraces recently that we consulted gen surg for. Your thoughts on chest tubes/pigtails and other surgical specialties being able to place them? It's unfortunately recently been a more common complication of robotic partial nephrectomies than we would like.

An NGT has a pretty easy learning curve, and you should be able to do it blindfolded without causing any serious harm to a patient. Even a novice can mess it up and not cause irreparable damage.

Chest tubes are different. Takes awhile to get good at them, and you can kill a patient if you do it wrong. I’m fine with any surgeon doing one if they have enough experience (most don’t). If a urology chief told me they did 30 chest tubes and are comfortable with the skill, I’d say go ahead. (I’d probably come watch out of sheer curiosity sake.) Have never come across that situation though.

Ive been putting more and more pigtails and thal-quicks in patients lately, and have been struggling getting our gen surg residents trained adequately in classic surgical tubes. It’s actually a big problem.

 

[armybound]

I appreciate the insight, everyone. Definitely opened my eyes to what the "expectation" should be of us. I can honestly say that we view it as a skill as don't really need, but we're clearly misguided. I'll have to encourage the team to attempt the NGT before calling a consultant and be present/assist when that consultant does come.

Also curious how other uro folks feel about other providers attempting Foley placement before calling for help. In my program we have zero expectation that anyone but a nurse has tried or that anyone could tell us what part of the attempt was unsuccessful. I'm wondering if that's common or not.

 

[Dr.LeoSpaceman]

I'm genuinely curious as to experience other specialties have with Foley placement. I imagine in the OR they're almost all placed by the circulator. I don't think I've ever gotten a call from a resident saying "Hey I tried some different things but still can't get this Foley.."

Either myself, another resident or a medical student place the foley in probably about 80% of the cases we do. Could we have the circulator do it? Probably, but I actually think it helps expedite things if I put it in while the circulator is busy doing whatever it else they need to do. I also think it's good practice, especially for a med student or intern. On the floor, I expect that my interns/juniors have tried themselves before calling urology. Why? Because I know how variable a nurses "attempt" can be. On one Foley, they "failed" because the labia was too swollen. Told me it was "impossible", though they didn't even try to expose before calling it a failure. They just decided it wasn't going to be possible. I put the foley in with minimal effort.

Same goes with NG tubes. Nurses often fail because they stop trying at the first sign of patient discomfort. Sometimes all it takes is someone who is willing to take their time and troubleshoot.

Not to be too offensive, but there seems to be some weak sauce going around at your hospital. The gen surg residents are ok with the consult to put in NGs as long as someone else manages them? Generally if I put in an NG, I (or my team) is managing it.

 

[armybound]

Either myself, another resident or a medical student place the foley in probably about 80% of the cases we do. Could we have the circulator do it? Probably, but I actually think it helps expedite things if I put it in while the circulator is busy doing whatever it else they need to do. I also think it's good practoce, especially for a med student or intern.

Not to be too offensive, but there seems to be some weak sauce going around at your hospital. The gen surg residents are ok with the consult to put in NGs as long as someone else manages them? Generally if I out in an NG, I (or my team) is managing it.

I will just say that it's a different sort of a hospital and educational system. It's not truly an academic hospital. We have some med students that rotate, but it's sort of a nontraditional set up (foreign med school, very uninterested students). So my med school experience was very student- and resident-run, but at this hospital the students do almost nothing and the residents are responsible for it all. We have a different hospital that's more of a traditional academic setup where the med students would be largely responsible for doing all of those sorts of things.

I think in general the gen surg teams are very busy and as long as they don't have to round on yet another patient, they don't really care if they just have to be the NG technician. Just like I don't care if I have to put in a Foley but I don't plan on following the patient unless there's a reason to (hematuria, etc).

 

[Vandalia]

I am going to jump in as an old man literally counting the days to retirement. There are several different aspects to this scenario that I think are worth pointing out.

1) There will come a time as a physician where you realize that you cannot get the immediate task done. If it hasn't happened to you yet, then you haven't been doing the job long enough. If it is only you, then you have to push through and do the best you can. If you have assistance available, you have to swallow your pride and ask for help. But the key point is that afterwards, you need to ask yourself why you failed and address the problem. Too tired? Then you need to cut back. Lack of skill? Practice. Too much caffeine? Cut back. Uncertain anatomy? Review the anatomy. Etc. (Note this applies more to attendings than residents, where the first at least isn't under your control.)

2) Now for "grumpy old man" time: One of my concerns is medical students and younger residents dismissing tasks as "scut" and/or "beneath them." However, an awful lot of medicine is a lot of boring, basic tasks. In the olden days, the lowest in the hierarchy often had to do "orderly" stuff like patient transport, bedpans, etc. After you get stuck in an elevator with a patient you never take for granted sending unstable (or even stable) patients around the hospital again. This wasn't hazing, at least primarily, there is some educational value in it. Ever talked to someone immediately after using a bedpan? Perhaps the next time you have a patient with trouble defecating, you might skip the expansive investigation and consider more "mechanical" problems first. I am not as good getting blood or starting IV's as our CT nurses, but I have done enough. You don't have to be efficient at nursing skills, but you need to know the basics. True, there is little marginal value after the 50th patient you have taken down to radiology, but there is probably value in the first 5-10. Here is the pearl: A surgeon is probably not going to get sued for a technical problem in a Whipple, but for ... not being able to get an NT in. Patient's, their families, and juries are usually very forgiving of mistakes in complicated tasks, but are harsh if you flub the most basic stuff.

 

[Kissmyabjj]

I don’t understand why everyone is razzing this guy, who came here with an honest question. How exactly are you supposed to learn a skill you have never been taught and only seen a handful of times?

When I was an intern I REALLY wanted to become proficient in placing central lines. Unfortunately, I was at a small non-academic hospital in which the surgical attendings only taught the surgery residents how to place them. I did 8 weeks of rotations with surgery and 8 weeks of ICU. You know how many central lines I was able to fight to be able to do? 1 and 1 line change over a guidewire. The rest of the time I had to watch one of the surgical interns or surgical PGY-2’s place them because they needed to become certified. Unless your program makes competence in a procedure a specific requirement for advancement, you may never learn how to do it.

 

[Smurfette]

We had a very unfortunate case recently where a patient died of aspiration after an attempted NG tube placement. The events leading up to the aspiration caused a lot of discussion at our M&M.

The patient clearly had an ileus and was vomiting and needed an NG tube. We asked the nurse to try, then the charge nurse when that wasn't successful. At this point we considered consulting general surgery for the NG tube placement, as none of us (urology residents) had any significant experience placing NG tubes. Basically we thought if an experienced nurse couldn't get it, those of us with 0-1 NG tube attempts ever wouldn't be able to get it either.

We mentioned this to our staff at M&M and got ripped apart. How could we be surgeons and not place NG tubes? How did we get through intern year without doing this? "When I was a resident...."

Bottom line, it's not something we do. I wouldn't expect a general surgeon or any other surgical specialty to be able to place a difficult Foley if a couple of experienced nurses have tried and failed. I wouldn't even expect a resident to try, as I assume they're not placing many Foleys, even in the OR.

Just curious of other thoughts on these sorts of situations.

I would expect urology to be able to at least try to place an NG, but this is based on the fact that the urology interns were rock stars in training and were putting in NGs left and right all year. We also expected med students to do them (I think I needed to place 3 as a student as a requirement on my surgery rotation at a different institution). I rarely do them myself anymore unless they are clearly not correctly placed and it's obvious when I see the patient. And to be honest, some nurses are terrible at doing it simply because an individual nurse often doesn't place a whole lot of them. Just because they are seasoned doesn't mean they are good at a given skill. They also love to put in inappropriately small NGs that coil because they are too pliable since RNs think a small tube hurts less. In practice, a truly difficult NG is something that I've seen get sent to radiology to place and bypass a surgical consult altogether. Those are normally due to anatomic issues. If you need a consult for an ileus, call me. Consulting me for NG placement but not for managing the ileus is...weird. If you are managing an ileus with an NG tube, you need to be able to manage the NG tube itself. It's a serious flaw in your training pathway that residents have literally only seen 1 NG placed in years of training. You are too spoiled by nursing. They aren't hard, plus you stick tubes in other orifices all the time and know what it feels like to have resistance or a problem advancing it.

As far as foleys, as general surgery residents we generally did pretty good as far as trying coudes in men or smaller foleys in women before calling urology. We placed them daily in the OR during residency, and were taught in intern orientation the steps to try if the first attempt at placement failed. The urologists have told me "if medicine calls for a difficult foley, I go see the patient with a regular foley and a coude. If general surgery calls and the surgeon tried, I know to bring a scope because they normally already tried the usual tricks and it actually will be difficult". Plus I've seen so many OR nurses (ok, and med students and to a lesser extent, residents) try to put a foley in the vagina or clitoris that I generally am not going to call urology and waste their time unless it's really needed. Plus I know I personally would much rather get a consult saying a physician tried and failed rather than a nurse tried and the doc didn't even give it a shot.

I realize that everyone's residency experiences are different. I went to a "residents have to do it to get practice" type of a place. That includes difficult blood draws and whatnot. As much as residents don't like doing this type of stuff, it has given me good troubleshooting skills that I can rely on in a pinch. While I rarely put in NGs or foleys myself anymore, I've done both of those things in the last month with minimal difficulty and saved the patients lots of torture in the process.

 

[armybound]

To stay along those lines, am I exposing myself to more legal risk by performing a skill I'm not very experienced with or good at when there are others around who are better? If I try an NGT and the patient has a bad outcome, will I be grilled by a lawyer for attempting NGT placement when I know I have a service readily available that's more skilled than I am?

I guess I'm not sure how to weigh the competing risks of not knowing a basic skill vs trying to employ a basic skill you're not good at but ideally "should" know how to do

 

[Smurfette]

To stay along those lines, am I exposing myself to more legal risk by performing a skill I'm not very experienced with or good at when there are others around who are better? If I try an NGT and the patient has a bad outcome, will I be grilled by a lawyer for attempting NGT placement when I know I have a service readily available that's more skilled than I am?

I guess I'm not sure how to weigh the competing risks of not knowing a basic skill vs trying to employ a basic skill you're not good at but ideally "should" know how to do

There aren't a whole lot of "bad" outcomes from an NG placement. Don't push it up into the brain; push it toward the back of the head. Get an X-ray to make sure it's not in the bronchus (if it's in the lung, pull out and try again) and don't put any meds or feeds into the tube without knowing for sure it's not in the lung. That's about it.

 

[armybound]

I would expect urology to be able to at least try to place an NG, but this is based on the fact that the urology interns were rock stars in training and were putting in NGs left and right all year. We also expected med students to do them (I think I needed to place 3 as a student as a requirement on my surgery rotation at a different institution). I rarely do them myself anymore unless they are clearly not correctly placed and it's obvious when I see the patient. And to be honest, some nurses are terrible at doing it simply because an individual nurse often doesn't place a whole lot of them. Just because they are seasoned doesn't mean they are good at a given skill. They also love to put in inappropriately small NGs that coil because they are too pliable since RNs think a small tube hurts less. In practice, a truly difficult NG is something that I've seen get sent to radiology to place and bypass a surgical consult altogether. Those are normally due to anatomic issues. If you need a consult for an ileus, call me. Consulting me for NG placement but not for managing the ileus is...weird. If you are managing an ileus with an NG tube, you need to be able to manage the NG tube itself. It's a serious flaw in your training pathway that residents have literally only seen 1 NG placed in years of training. You are too spoiled by nursing. They aren't hard, plus you stick tubes in other orifices all the time and know what it feels like to have resistance or a problem advancing it.

As far as foleys, as general surgery residents we generally did pretty good as far as trying coudes in men or smaller foleys in women before calling urology. We placed them daily in the OR during residency, and were taught in intern orientation the steps to try if the first attempt at placement failed. The urologists have told me "if medicine calls for a difficult foley, I go see the patient with a regular foley and a coude. If general surgery calls and the surgeon tried, I know to bring a scope because they normally already tried the usual tricks and it actually will be difficult". Plus I've seen so many OR nurses (ok, and med students and to a lesser extent, residents) try to put a foley in the vagina or clitoris that I generally am not going to call urology and waste their time unless it's really needed. Plus I know I personally would much rather get a consult saying a physician tried and failed rather than a nurse tried and the doc didn't even give it a shot.

I realize that everyone's residency experiences are different. I went to a "residents have to do it to get practice" type of a place. That includes difficult blood draws and whatnot. As much as residents don't like doing this type of stuff, it has given me good troubleshooting skills that I can rely on in a pinch. While I rarely put in NGs or foleys myself anymore, I've done both of those things in the last month with minimal difficulty and saved the patients lots of torture in the process.

Wow. This is very different from my training experience. I felt that my medical school was very good as far as requiring medical students to be involved, but I don't think I had any sort of requirement to even place IVs or Foleys. I definitely never tried an NG tube. They had a basic lab where we put one in on a mannequin, but that's it.

That's really interesting. And you know, I really don't even know how to troubleshoot an NG tube. I've had my attendings come in and start messing with them to fix whatever is wrong, and I don't know the least bit about it. This is making me realize I really know nothing about an NG tube except when the patient needs one and when it's ok to remove one. Definitely a big lack of knowledge there.

 

[armybound]

There aren't a whole lot of "bad" outcomes from an NG placement. Don't push it up into the brain; push it toward the back of the head. Get an X-ray to make sure it's not in the bronchus (if it's in the lung, pull out and try again) and don't put any meds or feeds into the tube without knowing for sure it's not in the lung. That's about it.

Well, I was thinking like aspiration and death. Which could happen to even the most experienced NG tube placer, but it's one of those things I worry about.

Like in the original post, if I had been the one who attempted NG tube placement and the patient aspirated and died, how would that be seen in court? Should I have had someone more experienced try it?

 

[Smurfette]

Well, I was thinking like aspiration and death. Which could happen to even the most experienced NG tube placer, but it's one of those things I worry about.

Like in the original post, if I had been the one who attempted NG tube placement and the patient aspirated and died, how would that be seen in court? Should I have had someone more experienced try it?

The patient likely didn't aspirate from the NG tube placement, more likely from vomiting due to the ileus with some emesis going down into the lung.

 

[vhawk]

Most of the important things have been covered pretty well so let me just comment on one thing. You said a few times "I figured if an experienced nurse couldn't get it, then I was unlikely to be successful." The following things about that statement are all, simultaneously, true:

1) your assessment of the situation is actually probably accurate
2) your assessment is very often used as a rationalization for being lazy
3) your assessment is something that every single one of us has said at some point during training, and most of us got away with it, most of the time
4) your assessment is completely indefensible in any sort of hindsight situation, be that legal proceeding, m&m, answering to your attending, etc

 

[armybound]

The patient likely didn't aspirate from the NG tube placement, more likely from vomiting due to the ileus with some emesis going down into the lung.

The vomiting and aspiration happened during the act of NG tube placement.

 

[Wordead]

To stay along those lines, am I exposing myself to more legal risk by performing a skill I'm not very experienced with or good at when there are others around who are better? If I try an NGT and the patient has a bad outcome, will I be grilled by a lawyer for attempting NGT placement when I know I have a service readily available that's more skilled than I am?

I guess I'm not sure how to weigh the competing risks of not knowing a basic skill vs trying to employ a basic skill you're not good at but ideally "should" know how to do

That line of thinking could be applied to anything within your field as well. Why are you attempting "X" urology procedure when there are others that are better at it?

 

[Smurfette]

The vomiting and aspiration happened during the act of NG tube placement.

Gotcha. It's pretty normal for patients to gag but that is completely unrelated to how experienced the person placing the NG is. So you are not, as an NG-placing novice, more likely to have a patient get this complication (gagging/vomiting) than someone who's done hundreds.

It would be hard to argue definitively in court that the tube placement caused vomiting when the patient was already at risk of vomiting and aspiration due to the ileus. The NGT is treatment for nausea and vomiting. The level of experience of the person placing the NG doesn't make a difference here or make you more or less likely to get sued; I presume a lawyer would argue that the NG needed to be in sooner, and that diagnosing the ileus earlier and/or having a tube placed earlier would have prevented the vomiting that led to aspiration and death.

 

[Gastrapathy]

Disagree slightly. If you're proficient at placing a NG, it happens fast. Banging around in the hypopharyx can cause more retching.

OP, when you say a nurse couldn't do it, why not? Couldn't get through the nose? Kept intubating the airway?

Just as an aside, it's worth being careful with weighted feeding tubes in intubated patients. They can pass by the ET balloon quite easily and catastrophically if you don't get an X-ray before advancing past a mainstem bronchus.

But...my biggest problem with the case is the belief that "considering" something is relevant.

 

[armybound]

But...my biggest problem with the case is the belief that "considering" something is relevant.

"Isn't consulting them without trying the same thing as them calling us for a Foley without trying it first?" That turned in to a discussion of how experienced we are vs nurses vs our consultants and who should try next.

There's more to the case that just shouldn't be discussed here. There were a number of issues with this case to be discussed and reconsidered. Several good points have been made throughout various comments in this thread that contributed to this complication.

I'm not sure what issue the nurses had with placement. I believe it had to do with resistance in the nose.

But again, I truly appreciate everyone's opinion. It definitely changed my point of view.

 

[cpants]

"Isn't consulting them without trying the same thing as them calling us for a Foley without trying it first?" That turned in to a discussion of how experienced we are vs nurses vs our consultants and who should try next.

There's more to the case that just shouldn't be discussed here. There were a number of issues with this case to be discussed and reconsidered. Several good points have been made throughout various comments in this thread that contributed to this complication.

I'm not sure what issue the nurses had with placement. I believe it had to do with resistance in the nose.

But again, I truly appreciate everyone's opinion. It definitely changed my point of view.

Urologist here. My experience in medical school and residency was very different. We did tons of NG's. That's because the nurses didn't do them at our institutions, so I understand why you may not have gotten the experience and why you may have mistakenly thought you didn't need to know that skill. You definitely need to know how if you plan on doing big surgeries or taking care of postop patients in your career. I think having nurses do most of the NG's is pretty rare.

Now that you have identified this deficit in training, your program should easily be able to rectify it. Lot's of urology patients need NG tubes if you are at a busy academic center and doing big cases. So, institute a policy that the residents, not nurses, have to put in all urology NG tubes. You guys should get trained up in no time. That's what M&M is all about--identify things you can change to improve outcomes next time.

 

[armybound]

Urologist here. My experience in medical school and residency was very different. We did tons of NG's. That's because the nurses didn't do them at our institutions, so I understand why you may not have gotten the experience and why you may have mistakenly thought you didn't need to know that skill. You definitely need to know how if you plan on doing big surgeries or taking care of postop patients in your career. I think having nurses do most of the NG's is pretty rare.

Now that you have identified this deficit in training, your program should easily be able to rectify it. Lot's of urology patients need NG tubes if you are at a busy academic center and doing big cases. So, institute a policy that the residents, not nurses, have to put in all urology NG tubes. You guys should get trained up in no time. That's what M&M is all about--identify things you can change to improve outcomes next time.

Sounds good. Appreciate your input.

 

[DoctwoB]

I don't think anyone is saying you should cowboy up and do things you're not comfortable with. I think people are saying you should be concerned that you don't feel comfortable managing a post op-ileus as a surgeon that operates in the abdomen.

There’s a lot of “holier then thou” going on in this thread. Urinary retention is a very common post op complication. Yet I am called frequently for post op “difficult Foleys” aka the nurse tried once and failed. Sometimes the resident gave it a shot or knew just enough to try something incorrect (e.g used a 12 French coude in a bph patient). Should you all not be operating because you can’t handle this common complication? The reality is that we have overlapping but different skill sets and sometimes need each other’s help, even for something considered basic. I do agree though that we should be making an effort to pick up these skills if we are lacking.

At our institution also most are placed by nurses. Personally I placed maybe 5 or 6 NGTs on Gensurg, and certainly would try before calling you, but also wouldn’t be surprised if I failed after the failure of the nursing staff. I agree that it is also germane to the consult, as we could then say why it was difficult rather then just “we couldn’t get it in”. Outside of cystectomies, it’s pretty rare for our patients to have a true ileus that requires an NG.

 

[SLUser11]

People are being too harsh in this thread. Another way this could have gone is a bunch of inexperienced urology residents trying to place the NG unsuccessfully for a prolonged period of time, which the patient doesn't tolerate, throws up/aspirates/dies, and we ask why they didn't find someone who knew what they were doing to get the tube in, as these poor attempts may have hastened the patient's demise.

There are lots of scenarios where the consulting team "at least trying" prior to calling is a bad thing, e.g. emergent intubation with prolonged hypoxia, foley placements where there's a lot of urethral trauma, lysis of adhesions (usually by gyn) with several enterotomies, NG placement where there's a lot of emesis and aspiration during several attempts, etc.

NOW, the reality is that the general surgery resident who would have been tasked with NG placement would have been equally inexperienced, so it may not have changed the outcome. Also, it seems a bit weak to ask for help with a simple task, so you would definitely have to eat s#@t from the consulted team. However, you have the patient's best interest in mind, and that's way more important than surgical ego.

You just have to present it clearly to the consulted team: "I'm really worried about this patient, and I don't feel comfortable doing the NG. Can you please come help me? I will be at the bedside to help, etc...."

I also disagree with "any abdominal surgeon should be able to do x..." There's too many small variations on this that are incorrect.

Finally, I don't believe the lack of NG placements by this resident is somehow an indicator that his/her training is inadequate, or at least inferior to yours. I would bet I can dissect through most residents' training and find a few weak spots. The most important thing is that these residents recognize their areas of weakness/inexperience and ask for help in a timely manner when necessary. It is then our jobs to not punish such requests for help by being snotty about the request, but instead to be helpful and pleasant, as eventually the roles will almost certainly be reversed.

 

[Gastrapathy]

@armybound i wasn’t saying don’t get help but rather that documenting you thought about getting help and then not doing so isn’t any protection against liability.

 

[ACSurgeon]

It’s important to clarify the notion that nurses are the most qualified for any given procedure. I’ve placed Foley’s and NGs that multiple nurses failed at. Not all nurses are made equal. Not all nurses correctly troubleshoot the reason for failing at their procedure. Some just try with more force rather than change their approach.

As a resident, knowing that a nurse failed at a certain task shouldn’t deter you from troubleshooting the problem and giving it an honest attempt.

Many failed NG placements are because the patient gets scared and tenses up, and the person placing the NG tube just tries to push harder causing more pain, bleeding and anxiety in return. If you take the time, stop when the patient tenses up, and try a more gentle technique, you’d be surprised how often an intern will succeed when a seasoned nurse has failed.

 

[Jolie South]

I am not going to pile on here. I agree with what has been said above. Find some way to get experience and take a stab at the NG when you have an issue with a nurse placing it. If I as a general surgery chief resident got that call for help, I would expect you to be at the bedside with me doing it and I probably wouldn’t be very nice about receiving the call.

Also, as with any patient issue, I have learned to take things with a grain of salt unless it is a super experienced nurse that I know and trust. Even then, just coming to assess the situation yourself in person, sometimes there are very simple things that the nurse didn’t think of that you can do differently. I also live by the motto of trust no one.

Furthermore, I have had some instances where the patient demands the NG be placed by a physician because of the perceived skill difference. I am happy to oblige.

 

[VincentAdultman]

I don't have anything to add, but I think I'm going to review NGT placement.

 

[Winged Scapula]

Agree that some of the early responses were unnecessarily harsh. Thankfully @armybound responded gracefully.

It is a slippery slope to say, “if you’re doing x, then you should be able to do/handle y”. We all need each other from time to time.

However I too was surprised at the lack of NGT experience; our Urology PGY1s were rockstars and spent a lot of time on GS learning those skills (several of our foregut surgeons would not allow nursing to place NGTs so we did a lot). I’ve also seen nurses (and residents) lie about trying procedures so take the idea that an “experienced nurse couldn’t get it so I wouldn’t be able to” with some side eye; most of the time IMHO it was an easy procedure that someone just didn’t want to do.

At any rate, lots of learning potential here for us all.

 

[Trauma Surgeon]

This is an interesting topic and I agree with the OP that some answers have been off the topic at hand…

Here is my question: how many attending urologist can place a NG tube? At my institution (although in Europe) none can!

Having done it during internship, no matter how many times, is not gonna help you 4-5 years later (or even more), in a patient were you have ancillary staff who does is it on a more regular basis have failed. I guess there is no foul in trying, but if you before hand know that your skills is not up for task in hand, call for help...

 

[armybound]

This is an interesting topic and I agree with the OP that some answers have been off the topic at hand…

Here is my question: how many attending urologist can place a NG tube? At my institution (although in Europe) none can!

Having done it during internship, no matter how many times, is not gonna help you 4-5 years later (or even more), in a patient were you have ancillary staff who does is it on a more regular basis have failed. I guess there is no foul in trying, but if you before hand know that your skills is not up for task in hand, call for help...

I was wondering if these expectations that urology place their own NG tubes holds at the attending level. I guess it's one thing to expect residents to do something at an academic hospital, but what about a private practice urologist?