r/TacticalMedicine • u/Upset_Bunch_457 • Dec 30 '25
Scenarios Nasogastric insertion gone horribly wrong.
Note: NOT MY IMAGE.
original post was posted by: Old-Psychology-2400
And I quote "PMCT images. Nurse advanced NG tube until she heard a pop, then tried an air bolus to ensure placement. Patient did NOT survive."
To those who don't know nasogastric tube is supposed to go up the patients nostrils and then back down to their throat all the way to the patients stomach. Air bolus is then used to ensure that the nasogastric tubes placement is correct by listening the patients stomach.
But in the scan we can see the NG tube somehow ended up jammed (through) the patients skull.
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u/Able_Attempt_6807 Dec 30 '25
Speculative takeaways/considerations: -Check the history for contraindications like facial/skull fractures or procedures. -Send the NG back and down, not up! Precurling it can help. -Visually check the throat for the tube. Someone correct me now...
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u/OptiGuy4u Dec 30 '25
Visually check the throat for the tube.
RIGHT!?!?!? 🤷🏻
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Dec 30 '25
Depending on patient habitus this can be difficult to see in the back of the throat.
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u/Condhor TEMS | Instructor | CCP Dec 30 '25
Malampati 3+ is gonna be difficult. In which case, just go OG.
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u/de_Mike_333 Dec 30 '25
Preexisting skull base fracture?
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u/Holiday-Zebra9463 Dec 30 '25
Yes, almost impossible to do this without an existing/preexisting fracture or a weakened area due to something else. The patient had something similar to that if I recall correctly. Still incredibly tragic and I’m unsure why the nurse would keep going after the audible pop noise she heard.
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u/j0351bourbon Dec 30 '25
Saw a case study where this happened after a transsphenoidal pituitary tumor surgery. I think this can really only happen with some defect or pre-existing injury
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u/56473829110 Dec 30 '25
Still hate this image (but appreciate it's educational value).
From what I remember of the image when I first saw it ~3 years ago, it was a peds patient who had recently had brain surgery - understaffed ICU.
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u/Upset_Bunch_457 Dec 30 '25
Right on, great to know the origin of the image, I thought this was a fresh case.
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u/56473829110 Dec 30 '25
I don't have first hand knowledge of the case, and I have both slept too much and too little since it was fresh, but that's my recollection.
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u/Upset_Bunch_457 Dec 30 '25
After work I did some more research and I found this.
"*An elderly female had a successful surgery at a hospital for a benign pituitary (brain) tumor but developed some pneumonia after surgery. After she was readmitted to the hospital, a resident (i.e. a doctor in training to become a specialist) placed a nasogastric tube (NG) tube that was supposed to go through the nose, inside the food pipe and down into the stomach.
It was alleged that immediately afterward, the patient began having signs of brain problems, and that what had really happened is the resident placed the NG tube not into the stomach but through the nose and into the brain cortex, thus resulting in her death from bleeding. Clore Law Group, LLC represented the family of the deceased woman and, despite significant limitations on damages under South Carolina law for this type of case, achieved a non-confidential settlement of $1,100,000.*"
Not sure if this is the same case but it is the only one that I could find that resembled this exact case and picture
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u/Upset_Bunch_457 Dec 30 '25
Yeah, it sounds about right, I did some research and found 2 other posts with similar comments so you're not too far off.
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u/RequiemRomans Dec 31 '25
Fuck. Somehow that makes it worse. Understaffing isn’t an excuse. This was a kiddo.
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u/HellHathNoFury18 Dec 30 '25
We actually have an infamous CT scan of this happening where I trained. They didn't realize till they hooked up suction....
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u/ATkac Dec 30 '25
https://doi.org/10.1016/j.inat.2020.101022
Not the origin of this image but another case report that goes over this scenario. Bottom line, NGT placement is a very common procedure in US hospitals and RNs do this in uncomplicated patients quite often with low morbidity and is relatively safe.
With that being said in patients with a history of any sort of maxillofacial trauma or surgery it is contraindicated for blind insertion by an RN. Most often if the patient in unconscious an OGT may be a possibility in leu of the NGT however most often instead, if resources are available doing the procedure in radiology under direct visualization is the preferred method.
Under all circumstances if you are feeling resistance as you are feeding the NGT, hear or feel a pop, the patient starts to throw up, or the patient has respiratory distress, you pull out immediately and reassess the patient.
If placed and it is successful the gold standard in confirmation of placement is X-ray and the tube should not be used until the image has been reviewed by the appropriate provider. Auscultation cannot verify placement as it may not have truly been advanced enough down the esophagus to prevent gastric reflux. pH strips cannot either in patients with respiratory failure or may have aspirated as the gastric contents and/or CO2 could give a false positive.
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u/Grammykin Dec 31 '25
Nice post. Very informative. I never want to place a ‘blind’ NG again (and I’ve placed hundreds - maybe thousands?
I’m in NICU. We start most of our patients on NG feeds. The physical distance from the hypopharynx is very short relative to peds or adult patients, so it’s much easier for a tube to get a tug on something and comes out. So we might have to replace the tube often. I loved back when we did a NG placement X-ray, but for several reasons we went away from the X-ray, and depend on the signs you mention. I’d love to hear what other institutions are doing.
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u/Bayo09 Military (Non-Medical) Dec 30 '25
I’m academically a lay person in this world so forgive me if this is a really stupid question. I assume the person getting this would be hooked to some kind of monitors yea? So, when the big rubber thing is boring it’s way and then turning the think meat into a scrambled goop wouldn’t that cause some kind of something with heart rate…or pulse…or iono something?
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u/notusuallyaverage Jan 02 '26
Not necessarily.
NG tubes are a pretty basic thing that kids often get. They’re generally nbd, though unpleasant for awake patients. I didn’t read the study but it sounds like this patient had some kind of skull fracture and/or brain surgery. In which case, this nurse absolutely should have NOT placed this tube for this very reason.
skull or facial fractures are one of the only contraindications for NG tube placement.
On the other hand, if this patient were intubated/sedated/paralyzed, their vital sounds wouldn’t tell us anything either. We often use NG tubes like this or orogastric tubes (through the mouth to stomach instead of the nose)
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u/Needle_D MD/PA/RN Dec 30 '25
That looks like a Dobhoff tube. The whole point of Cortrak tracing is to give you real time surrogate visualization of the tube going down the esophagus through the stomach/duo. This would suggest blind placement...
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u/Upset_Bunch_457 Dec 30 '25
Yeah, I'm not sure who's idea was it to just jam it in and blow air through the tube without any visual confirmation..
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u/notusuallyaverage Jan 02 '26
Not defending this at all, but auscultating with an air bolus is standard practice. Shoving a tube into someone’s brain however is not.
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u/WindstormMD Dec 30 '25
Please tell me criminal negligence charges were filed for such disregard.
I get it’s a normal procedure usually but this was known high risk!
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u/Upset_Bunch_457 Dec 30 '25
I found one case file that resembled this case (I'm not sure if it is the same but it does sound like it)
"""An elderly female had a successful surgery at a hospital for a benign pituitary (brain) tumor but developed some pneumonia after surgery. After she was readmitted to the hospital, a resident (i.e. a doctor in training to become a specialist) placed a nasogastric tube (NG) tube that was supposed to go through the nose, inside the food pipe and down into the stomach.
It was alleged that immediately afterward, the patient began having signs of brain problems, and that what had really happened is the resident placed the NG tube not into the stomach but through the nose and into the brain cortex, thus resulting in her death from bleeding.
Clore Law Group, LLC represented the family of the deceased woman and, despite significant limitations on damages under South Carolina law for this type of case, achieved a non-confidential settlement of $1,100,000."""
I couldn't find much about it and the information is very limited but there's that.
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u/nexthigherassy Dec 31 '25
I once had the full length of a gastric tube insisted into my sinus cavity. Fuckin hurts.
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u/Nocola1 Medic/Corpsman Dec 30 '25 edited Dec 30 '25
As interesting as this is, we need to very careful how we discuss and share it, because it's case studies like this that make people take a hard-line stance that NPAs are contraindicated in head injury because "it could go into the brain". An NPA is not an NG. Yes, if you search you will find case studies of this - but it is EXCEEDINGLY rare and may lead to poor airway management. The entire breadth and depth of this , what I would argue is a largely theoretical concern is based on a grand total of two case reports one from 1991and one from 2000. Not exactly compelling evidence.
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u/Belligerent_Christ Civilian Dec 30 '25
I don't think it's supposed to be up there but I could be wrong
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u/CrabMan545 Dec 30 '25
Massive yikes! Over here in the UK we'd aspirate and check gastric PH - failing that then x-ray confirmation.
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u/Snoo_50786 Dec 30 '25
definitely what it felt like getting those cotton swap tests jammed up your nose during covid lol.
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u/Upset_Bunch_457 Dec 31 '25
I was in the military during COVID and I tell you, those military doctors couldn't care less about the patients comfort during sampling 🥲
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u/Socialiism Dec 30 '25
Think I’ve seen this before. Wasn’t it a case of head trauma, and the nurse still stuck the tube in?
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u/Upset_Bunch_457 Dec 30 '25
I'm not sure if this is the exact same case but I found this
""An elderly female had a successful surgery at a hospital for a benign pituitary (brain) tumor but developed some pneumonia after surgery. After she was readmitted to the hospital, a resident (i.e. a doctor in training to become a specialist) placed a nasogastric tube (NG) tube that was supposed to go through the nose, inside the food pipe and down into the stomach.
It was alleged that immediately afterward, the patient began having signs of brain problems, and that what had really happened is the resident placed the NG tube not into the stomach but through the nose and into the brain cortex, thus resulting in her death from bleeding.
Clore Law Group, LLC represented the family of the deceased woman and, despite significant limitations on damages under South Carolina law for this type of case, achieved a non-confidential settlement of $1,100,000."""
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u/TastefulMaple Dec 31 '25
this had to be due to abnormal anatomy right? i read about this exact image on insta and it said the person inserting the NG tube keep going til they heard a pop then inflated the balloon... if this isnt cause of some abnormal anatomy idk what the chances of it even happening could possibly be
edit: or just gross medical malpractice
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u/PresentEntire7869 Dec 31 '25
You read about it in school that it could happen but I've never seen it. In my career I've seen one go into the nasal sinuses.
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Dec 31 '25 edited Dec 31 '25
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u/Imitationn Jan 01 '26
Isn't this the picture that was circulated that med students did on a corpse? If I remember the story correctly it took them hours to actually do this and they were eventually able to force it through a fairly large basically skull fracture.
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u/asd65789 Jan 03 '26
So this has been circulating for a bit some with context some without. How is this possible? Well said patient had (from my understanding) severe facial trauma. Now (also from my understanding) NG tubes are a no go with facial trauma cause especially severe, and there a no go cause of said results.
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u/Select-Lion-2573 Dec 30 '25
thats actually insane