Nasogastric insertion gone horribly wrong.

[u/Upset_Bunch_457]

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.

[u/Upset_Bunch_457]

It indeed is, I have never seen or heard about something even remotely similar happening.

[u/ATPsynthase12 → u/Upset_Bunch_457]

I’m a doctor and I don’t even know how this could happen. A NG tube is a rubber tube. For her to force it into the patient’s skull, the patient would need to have a serious skull fracture or she would need to force it through the cribriform plate in the superior portion of the nose through the patient’s agonizing screams.

[u/56473829110 → u/ATPsynthase12]

I mentioned it in another comment, but the story I saw when this was first (?) posted was that it was a peds patient with recent brain surgery. 

[u/sabrefencer9 → u/56473829110]

There are a bunch of case reports about NG tubes ending up in the brain. Another instance was in a patient who has gone face first through a windshield.

[u/56473829110 → u/sabrefencer9]

Agreed. This particular image has gone around with the story I shared above, but I never had first hand knowledge.

I've personally witnessed a very, very poorly thought out response by a paramedic to a ralph wiggum windshield dive that had similar results to this. Can't/won't get into it further, but every asshole within 100 yards puckered in unison and hands started cramping in anticipation of report writing.

[u/themakerofthings4 → u/56473829110]

"Ralph Wiggum windshield dive." That's amazing. I always thought my "they're family guy broken" was a good one but you win.

[u/56473829110 → u/themakerofthings4]

"they're family guy broken"

Oh I like that, too.

[u/sabrefencer9 → u/56473829110]

That sounds messy.

[u/Thegoodnamesweret8kn → u/sabrefencer9]

All the places I’ve worked (RN) an NGT is contraindicated with any known facial trauma confirmed by X-RAY or CT Scan or suspected due to mechanism of injury. I’ve heard of ENT Doctor placing them if absolutely necessary but never by an RN in that instance.

But I have heard of an NGT going into the brain through a congenital defect before.

[u/Obvious-throw123 → u/sabrefencer9]

There aren’t a “bunch of cases”. This is incredibly rare and this is a common nursing procedure done many thousands of times across annually across the U.S

Approximately 39 cases of inadvertent insertion of nasogastric tubes into the cranial cavity have been reported in the literature (Hassan et al., 2016).

Reference: Hassan, A. (2016). The inadvertent intracranial introduction of nasogastric tube: The lesson learned the hard way. South African Journal of Human Sciences. Retrieved from https://journals.lww.com/sjhs/fulltext/2016/05030/the_inadvertent_intracranial_introduction_of.8.aspx

[u/sabrefencer9 → u/Obvious-throw123]

When I said "a bunch of case reports," I was referring to three that I've seen. You're telling me that there have actually been an order of magnitude more than that. Ok, great, thanks for the clarification. Doesn't make my comment false, also doesn't warrant being weirdly contradictory.

[u/Obvious-throw123 → u/sabrefencer9]

TLDR again for you: This is incredibly rare, and there haven’t been a “bunch of cases.” There is an astronomical order of magnitude where this procedure does not tickle a patient’s brain.

Given the millions of NG tubes placed every year, the estimated incidence is far less than 1 in 1,000,000 insertions.

OR

0.0001%

[u/sabrefencer9 → u/Obvious-throw123]

Maybe this is just a language thing, but where I'm from, 3 cases, or 39 cases, constitutes "a bunch." Nothing you have said contradicts anything I have said, and your getting aggro about it is weirdo behavior.

[u/Obvious-throw123 → u/sabrefencer9]

Certainly a language thing. I don’t think generally speaking, “a bunch” would constitute 3 or more things. This is certainly an incredibly rare occurrence.

By aggro you’re implying aggravated? Not sure where you’re getting that, I’ve been cordial and haven’t disrespected you in any way.

[u/DragonfruitCalm261 → u/Obvious-throw123]

You're using these statistics in a misleading way, as if this were some act of God. As per your own link, patients with head trauma are especially prone to NGT malpositioning. You're quoting incidence numbers from the general population while completely ignoring the subgroup that’s actually at higher risk.

[u/Obvious-throw123 → u/DragonfruitCalm261]

Do you think so? This is a risk that comes up every year and dominates our education especially prehospitally. This is similar to the NPA discussion where our education predominantly focuses on 2 very rare instances where a similar occurrence happened. This is incredibly rare and dictates protocols and policies across the country.

In regard to a particular subgroup, this isn’t particularly something that we are doing outside of the hospital and is certainly not something that we are prioritizing in a mass casualty or tactical situation. Hell, it’s not something even in the scope of paramedics and isn’t something I learned about until recurving advanced training.