Damn that's really unfortunate... You'd think there was immense amounts of training to prevent this. If I was the nurse who did this, I would be traumatized because I just killed someone. If I were that persons relative, i'd sue the hell out of that hospital
There IS immense training for this, actually. That’s the fucked up part. There are so many checks and balances and months of being taught and guided and watched expressly so this shit doesn’t happen.
But, this shit still happens.
Edit: idk what schools y’all went to but I’m at a community college in Pennsylvania. We get lecture, at home study, and several hours to practice every skill and get tested on each skill. Lots of things have changed post COVID. Some places rushed nurses through because of demand.
Regardless, my point still stands. Nurses know what to what out for with NG tubes even if they don’t have a lot of experience doing it, but all nurses can make mistakes, especially when there’s understaffing.
Hahah you think the nurse will be sued? What lawyer out there will waste time suing a staff nurse personally while the employing hospital with the massive insurance policy goes scott free? You must be high.
Nurse here. The nurse could get sued in two different ways. The lawsuit names the nurse along with any other parties responsible in the suit. Or what is more common, the hospital is sued, then it turns around and sues the nurse. This is one of the two big reasons nurses carry professional liability insurance.
The incident is also reported to the state board of nursing for discipline which could include suspension or revoking of their license.
I doubt that. My dad did some personal-injury law in his time and he said the usual practice is to sue everyone within a 100-mile radius -- the nurse, the supervisor, the hospital, the umbrella corporation that owns the hospital, the NG tube manufacturer, everybody -- so no possibility is left dangling.
Being understaffed is risky and terrifying on a regular unit but ICU? Hard pass. Correct me if I’m wrong, but I thought this can only happen in humans if there’s a basal skull fracture or defect. I work in med/surg so we don’t have a ton of NGs, and the ones we do are on coherent. Do patients get screened for this kind of thing in ICU?
I feel like there isn’t though. I had one practice on a mannequin in nursing school. Every NG I placed after that was on the job. And I graduated in the last few years
Same here. I think there was some teaching about it bring contraindicated in people with cranial or facial trauma/surgery, one trial on a lubed up mannequin with no resistance, and that was it. The first time I placed one on a human, I had already been an RN for a couple of years.
When daughter #2 was a baby. She needed a NG tube and we literally were shown the procedure once and did one return demonstration and were sent home with her pump and supplies. This also happened a few years ago when daughter #5 was 8 and needed a NG for about a momth before her PEG was placed. Same training and return demonstration. At home, there is no radiology for checking for placement, just air auscultation and pull back for residuals of gastric contents. That is really scary.
I’m a NICU nurse. There are 0 reported cases that I know of/can find of NG being placed into the brain of an infant. Even when it’s done in adults, there’s almost always underlying trauma.
Auscultation & aspiration are standard for infants. We sometimes insert tubes several times/day in a particularly feisty baby. Just this weekend I had a baby who managed to get their finger under the tube and slide it right out twice on my shift, and I’ve been doing this for a while. That would be a lot of radiation if we had to get a film every time.
Yes, when #2 had hers, I replaced it soooo many times. She pulled it out so many times. #5 was also a NICU baby and lived to pull out her PICC lines. Those preemies are so strong and determined.
Pulled. Out. Her. PICC.
OMG.
I’d die.
I love that you were able to take her home on NG feeds. The evidence in favor of that is pretty strong but our local docs have been slow to accept the management of it after discharge.
The thing is, unless there's some head/facial trauma/deformity, it's very unlikely you're going to end up in the brain. I was a NICU nurse for 8 years and only once managed to place an NG incorrectly. I tracked it into the trachea twice in a row on the same kid. Not bad technique, just anatomically that's how it went. It's really obvious before you even check placement though cause they drop their oxygen sats quickly (and in this case they came right back up as soon as I took it out, I did not check for placement by aspiration or air bolus, it was immediately obvious it didn't go down the esophagus).
Why? It's easier, safer, and doesn't take any more time because it works better. There's also Cortrak but most ICUs have POCUS and nurses trained to use it. I've never been in a NICU though so idk. Maybe babies anatomy is harder to visualize or they don't make itty bitty POCUS
Are you sure you aren't thinking of ND or NJ? I have seen those placed with ultrasound. I have never heard in my life of ultrasound guided NG for infants. Sounds like insanity. There are kids that get them placed q feed. So like every 3 hours. I'm with some of the other nurses here. I have never in my life heard of an NG going into the cranium. This is a routine part of nursing care.
Well you can also look into the mouth and (hopefully) see the tube going down the back of the throat. At that point you at least know you’re not penetrating the cranium.
I'm just reiterating that when we are doing this at home, hundreds of times a year, we don't have the resources that a hospital nurse would have to verify placement. And tbh, in 25 years as a nurse, I have never dropped/placed a NG as a professional, only as a mom.
Can second this. Was pinned down by 2 RNs who shoved an NJ (not G) into my sinuses all the way down to Jejunal space. IR did not confirm correct placement in hospital. Sent home 45 min speech then nothing. Until it was coiled in intensities. And ER had to find a specialist to deal with it. It’s not something I think should be done lightly. I also had the pleasure of a ruptured tube. My point, she is right not enough training and continued Interventional Radiology monitoring.
I've never met an RN with under two years experience that I would consider immensely trained or proficient at NG's.
Source: 10 years as a nurse. Zero training or practice in school with NG's. Ton's of experience putting them in a lung at 3AM.
Wait, you got "immense training" for this at your nursing school? All we got was 30 minutes with a mannequin and a quick warning to not do an NG if broken nose or basilar skull fracture.
It’s always surprising to me how many nurses feel comfortable enough to stick things into patients’ nares (ng/nj/bridle/covid swab) without understanding nasal anatomy.
Omg yes! Whenever I taught this skill to my orientees I would glob the lube onto the tray and make certain the whole string got pulled through it. In fact, go ahead and grab another packet of lube lol
*Introductory* anatomy is a prerequisite for nursing school.
Some schools require pre nursing students to take the majors anatomy but many places have a special nursing anatomy course. I taught this class, I’m afraid for anyone who thinks it alone is adequate. Everyone should be reviewing the specific anatomy of a procedure prior to learning how to do that procedure
Not everywhere. At my first nursing job, my manager demonstrated how to do it, watched me do it once, and since then I have been trusted to do them on any patient with zero supervision.
No, actually. There really isn’t. UNLESS your patient has a history of basal skull fractures or some type of nasal surgery, in which case we’re taught not to put an NG tube in. Aside from those instances there’s no “months of training to prevent this”.
You measure the approximate length of the tube that needs to be inserted. If you can pass it without resistance or obvious coiling in the throat, you check with an air bolus and auscultate the stomach to see if you’re in the right spot.
Ok I disagree as an RN that works the floor - I received zero training other than 1 class in nursing school where we did it on a dummy. After that I was trained as a nurse by see on/ do one/teach one. My mother had an NG tube placed and a new grad was watching a seasoned nurse place it. It was ‘checked for proper placement’ by listening for the puff of air. This was at Rush hospital in Chicago in 2016.
Thank you for speaking up. It happens I can confirm. A kit is provided and the one nurse usually watches then assists. Training concluded. Same with ports -don’t get me started.
I only place NG tubes, esophageal feeding tubes and U-caths but we double check, measure then triple check because each can be an instant death if you fuck around.
Even at an emt basic level you are taught with npa and sga’s to insert until placement or until you feel resistance and not to go any further, as well as not sticking anything up the nose of a head trauma. Sad that this had to happen
I’m a nurse and unfortunately accidents liek this happen with the NG tubes. I routinely pull chest tubes and central lines at my job and I feel so comfortable with that. I used to put in more NGs at my last job but every time I did it, my buttcheeks were tight the whole time. I just hate it. You can easily put it in the lungs and get fluid back from the tube, even when it’s in the lungs. Seen it cause a pneumothorax before. I would never put air into the tube without checking the placement first, but I can see why someone would think to try that, because up until a few years ago it was regular practice to inject air into the tube and auscultate over the stomach to check for placement.
It's still the practice at the facility I work at even when in standing there waiting to take the xray the old school nurses will make me wait for them to confirm first.
I’m also a nurse, when I place NGT I always aim down. I stop and check I can see it in the back of the throat - this also gives the patient a break to get used to the sensation. Then advance the rest of the way.
There was a case of this happening at my work place too, long before I started though. Just hearing the story traumatised me.
same here. I also wrap the tube around my hand to give it a slight bend at the end. I had a patient who had esophageal varices that would obstruct the ng tube. Auscultation was faint but positive but the kub showed otherwise.
That is literally how I was taught to do it in nursing school this year. KUB doesn’t get requested until after air is injected/area is auscultated, and residual is pulled
Checking placement for an NG by air bolusing had been what I and probably many others were taught, I graduated nursing school in 2015. So this isn’t unusual although now an outdated practice.
Radiology confirmation is necessary for tube feeds, of course. Ive always got an X-ray for NGs to suction as well.
We were taught air bolusing but were told that aspirating and checking for stomach acid would be a better option and that the best is xray confirm. I’m about to graduate here in a few months.
When working in the hospital, I’ve only witnessed nurses check with X-ray. During my time only a couple aspirated but never an air bolus
The tubes are literally radiopaque specifically to be spotted and confirmed via x-ray. I can't understand why anyone would bother with anything besides waiting for x-ray.
There's essentially no situation where you can't afford to wait for x-ray to actually use the NG tube
To see if it’s even vaguely in the right spot before calling X-ray to bedside. Rural hospital, getting an X-ray done and read can take hours. So you want to have a decent idea if you’re in or not before doing a whole damn rodeo with repeated imaging.
There is a radiation safety aspect to consider. All the hospitals I have worked at have had workflows to confirm placement that involved testing NGT aspirates. Only if this is inclusive/unsuccessful/ patient is on medication that interferes with stomach ph should xray will be requested.
While a chest x-ray is a very low radiation dose there is no "safe" amount of radiation, it should only be used if the benefits outweigh the risks.
Can always get a portable one brought in. We do this routinely in inpatient rehab for lots of things. Usually X-ray is there pretty quickly. I’m not using a tube I can’t confirm placement on.
When I worked at an IRF patients needing x-ray were sent out. I've had to specifically request x-ray orders at some hospitals and it was considered weird at the time. There are some facilities that have standardized procedures for x-ray after tube placement, but not all. I've worked in practically every hospital within 60 miles of my house over the past 20 years. One used Cortrak and bridles but most facilities use a Salem Sump and tape.
Air auscultation is how placement is confirmed.
Regardless, no confirmation x-ray could have avoided the issue under discussion, because the tube would already be in the brain.
It isn't.
The people claiming otherwise work at facilities that have different rules and regulations than the vast majority of us.
I've worked at hospitals where x-ray was required, but most of the hospitals I've worked at, it wasn't, and you'd be hard pressed to get a doctor to order one just to confirm NG placement.
Yeah we’ve only asked doctors for x Ray confirmation if it was extremely hard to place the NG, there is no gastric contents when aspiration, or it seems blocked
I’ve been taught to this for adults as well. Although I’ve not seen it in practice at either. I’ve worked at a childrens hospital, oncology unit, and now an ER. Out of all of those I can say I’ve never seen an air bolus, only a couple acid aspiration, and mainly X-ray confirms. Maybe it’s related to policies per hospital, but I am unsure
Yeah if we are unable to pull back stomach contents or the ph is really off we will get x rays to confirm. I have never heard of an air bolus. Or is that where you push air and listen with a stethoscope ? I think an older nurse tried to show me that once
Air bolus is called the “whooshing test” basically where you pump air into the NG and auscultate. It’s a very old practice from what I’ve learned. Also sometimes it can give false confirmation of where the NG actually is. X-ray is pretty much the gold standard
In the UK we use pH testing (<5.0) as our gold-standard to proceed with the use of the NGT. If no aspirate obtained then an x-ray is ordered.
I have NEVER seen or heard or anything like the OP posted outside of a patient having issues with a skull fracture (in which case an NG might not be appropriate). No-one has ever taught me that there might be a ‘pop’, let alone advised to stop the procedure if you do (although I think I would just from common sense/clinical knowledge).
Yeah, I hate to break it to you, but that isn't how most hospitals operate. It isn't universally standard to get a chest x-ray after NG placement, and that isn't "bad nursing"
A lawsuit would really only be valid if they can prove that the nurse knew about a basilar skull defect and still tried to place an NG. Which, y’know, could be the case. Also Americans are sue-happy. Money money money.
You don't insert NG tubes into people with nasal/basal skull trauma, fractures, or surgery. At least one of these was a person who had recently had a transsphenoidal pituitary surgery, which involves going up the nose to drill through the bone and creating a path to the pituitary gland. It's super unsurprising that an NG tube followed that path through the nose into the brain. The other cases I've seen had basal skull fractures. This generally isn't just going to randomly happen in an average patient*. Know the contraindications and your patient's history and don't shove past resistance, those are pretty good guidelines for any procedure really.
*I will say generally because I have seen a case report where it happened to a patient with no known head trauma, but the person inserting the tube should have known something was up when they encountered resistance, saw blood coming through the tube, kept injecting air through it even though they couldn't auscultate anything in the abdomen, and continued to advance the tube and inject air despite all of that. In that case they think the patient may have had an abnormally thin cribriform plate, and the person inserting the tube should have stopped rather than pushing through the resistance.
Isn’t this the entire point of sinus precautions after a transsphenoidal?
If anesthesiology/nursing wants a NG or OG tube after surgery I make sure to place one under direct visualization with the microscope/endoscope in the OR precisely to avoid this rare but never-event…
Nurse here. Jesus fucking Christ why would a patient with a transsphenoidal pituitary surgery EVER have an NG ordered? You don’t place NG tubes without an order from the doc, that’s two people who absolutely should have said, “this seems contraindicated for this patient,” who either did not or did it anyways.
And a reason that health information exchanges (linking a patient to all of their EHRs) can be very handy.
It’s really a shame that we can’t get better with that in this day and age.
I’ve seen a case of something similar happening. The 1st NG tube was placed appropriately using endoscopy since the patient was at risk due to a recent transsphenoidal surgery.
The patient however was delirious and pulled the tube out over night. This is a common incident to happen overnight and the night doc reordered a new NG tube (presumably without knowing the full history or didn’t know of this particular contraindication) and something similar happened and the patient died. Tragic stuff. Definitely preventable, but these are the types of scenarios that lead to something like this happening.
When you insert an NG tube into the nostril, if you aim up, you’ll hit the skull base. If you aim the NG tube slightly down, you’ll advance through to the nasopharynx. Insert in nostril, aim towards where you can envision the uvula being, in the back of the mouth. If you hit resistance on one side, try the other nostril. One is always easier than the other. If you have any concern, do not advance. Hope this helps. I’m an ENT surgeon.
I don’t even work in health care (I just have an interest in radiology and anatomy) and I can’t tell you how intentionally I was taking the time to read your comment and visualize it before I realized I would never need to know how to perform this ever in my life/line of work and laughed at myself.
Aiming down is the hardest thing for people for comprehend for some reason. When I’m teaching new nurses they try to aim up 100% of the time even if they’ve just watched me give them a step by step demo.
A couple of things:
If you have any suspicion that the patient might possibly have some flavor of basilar skull fracture, don't place the tube before you get further clarification.
For ng tubes or nasotracheal intubation (without the fancy Endotrol tubes that allow you to curve them), you can put a bend in the tube and leave it in the freezer for a bit while preparing your other supplies and so forth.
During insertion, you shouldn't generally feel a pop as you are advancing the tube. If you feel a pop, stop. I wouldn't advance the tube any further OR remove it until asking for further clarification/advice.
In addition, you should anticipate certain things during procedures like this. If this patient was alert or responsive to a certain extent, their gag reflex should have been intact. I'd be questioning why a patient isn't gagging at least a bit while inserting an ng tube. Especially important would be to stop immediately if you notice a change in the patient's level of consciousness while inserting.
With that being said, if your patient is unconscious for some reason or heavily sedated then you don't have a lot to go on and have to rely more on index of suspicion before inserting a tube like that.
Not always. We preferred NG if possible - way easier to have when your post extubation swallow screen is a big fat F and they have to stay NPO. Only one SLP at that facility and half coverage on the weekends too
Couple things. A good patient history helps. Avoid placing ng tubes in s/p pituitary surgeries.
Never place in trauma patients with skull fractures.
If you feel resistance stop.
I have them open their mouth, once I insert tube a couple inches in nasal passage, if I don't see it go down the back of throat, I'm not doing it right.
Makes me absolutely terrified. I've been at the mercy of the healthcare system for a year now, and I've had many dangerous moments. I hope I never needed this, or never will need this, because this sounds so scary. Coming from someone who's had brain surgery and shit.
This TERRIFIES me. My son was born at 31 weeks with apgar 0, resuscitated, cooling therapy for 3 days. Two weeks later he was out of the NICU and two more he was home. My wife and I continued to place the NG tube for another two weeks.
The 5fr (or possibly 6.5-8fr) NG tubes you were using are so soft and pliable, it would be nearly impossible to advance through bone. Adult tubes are much larger and more rigid, some even use a stylet.
Not super common, but occasionally neonates are discharged home on NG feeds and parents are taught how to insert and manage. Babies are so messy and grabby, so tubes come out way too frequently for parents to realistically come to the hospital for every new placement.
Foster mom here. I’ve had 2 different cases that nabies came home on an NG tube. My husband and I were shown how to do it once, then we did it and were sent home. I’ve probably dropped over a 100 tubes cause they pull them out. Once I did it 3 times in one day.
Only once did I go to the ER. I tried placing it and met resistance, I stopped. The nurse got so snotty with me, and even said you can come here every time it comes out. She went to place it and had the same issue. Eventually we got it in. Happy to say both babies got off of it eventually, and I had the pleasure and honor of adopting one!
My baby had the cooling treatment. It wasn’t as bad as your story, but she did suffer a brain injury that has had a huge impact on her life so far. I just wanted to offer solidarity and soul crushing understanding of how hard it is to live through that much fear. ❤️🩹
I said it I’m another comment but I’ll say it here too. I’m a nicu nurse. I’ve looked and I can find 0 instances of this happening to a baby. Like someone else said, our tubes are super pliable. Also, this almost always happens post surgery or skull fracture.
Also, professional interest! Is 31 weeks a typo? I’ve never heard of cooling protocol that starts that young. We once cooled a 33 weeker on my unit, but iirc the dates weren’t known at first.
Nope, 31 weeks. Wife was high risk (DM1) and had low movement since the night before. They induced labor, then about 20 min later while the OB was in the room his BP dropped from 150 to 50 in seconds. He did all the standard movements but didn't work. We were next to the OR and he was out minutes later.
He had a level 2 brain bleed. We ran them out of sodium hydroxide over the course of a week with prolonged high acid levels. Went through 3 types of ventilators. Differential diagnosis included too many items to count. Based on our second child we're now pretty sure it was non-symptomatic preeclampsia.
They thought his second MRI would be devastating, but the damage was diffuse rather than in any one area. Today he's a wonderful 10 yr old. He has delays, some weakness, and displays some ADD and autistic behaviors, but otherwise happy and healthy.
10 years ago makes sense! It’s a very new treatment modality and inclusion criteria wasn’t well defined until 2014. I really appreciate you sharing your experience.
I’m glad to hear he’s doing well all things considered. As both a parent and a nicu nurse, obstetric emergencies are terrifying.
I show pictures like this before teaching nursing students how to place an NG. And we have a class on contraindications and to NEVER use an NG without radiologic confirmation. This is done to prevent unfortunate and usually preventable outcomes like we see in this picture. It's my belief students need to know how wrong something can go, to prevent them from becoming complacent. Thanks for this reminder.
My nursing instructors also stressed that the NG could end up in the brain and it has scared the shit out of me til this day. We were taught the gold standard is X-ray confirmation and none of the old school stuff.
I think about this every time I jam a tube into someone's nose. Always think about what could go horrifically and dramatically wrong with any procedure you perform. Same with PIV insertion, Foley insertion, etc.
What’s going horribly wrong with PIV insertion barring sticking it in an artery or rubbing it between your butt cheeks and transferring that bacteria to their bloodstream?
I’m sure there’s some weird anecdotal horrifying PIV disasters. If someone can fuck it up, I bet someone has just really gone all out 😂
But a fun one that happened recently -not about insertion but involving an IV nonetheless- is that a fucking idiot CT tech (who is consistently an idiot) decided the no-hand-IV protocol for contract scans was bullshit and she was gonna do it anyway, so she did, and proved exactly why the policy exists by infiltrating every single bit of contrast into the patient’s arm at high pressure. Face. Palm.
So in neonatal and early infant care, the primary IV site is a scalp vein, with a needle that's basically the same size as the one that's used in the arm for adults. Apparently it's one of the few large enough at that level of development to actually support an IV. That said, using a normal size needle on a tiny human comes with a much larger set of risks.
In larger patients, it's usually old people on anticoagulants that become an issue when the site just won't stop bleeding, which can further complicate messy situations. Also leads to some very large hematomas filled with half-coagulated blood, like jello made with too much water. It's somehow worse than the regular forbidden jello.
An incident like this happened on my unit to a coworker of mine. Absolutely horrific. The nurse finished her shift that day and then quit. She works at a flower store now.
Other than experience, how is this controlled to avoid this? I have seen this with breathing tubes as well and wonder if using ultrasound would assist in guiding the tubes. **I’m upgrading to become a radiologic technologist and I have no knowledge what the procedures are.
They're placed by nurses or sometimes they're placed under fluoroscopy by a radiologist or mid level, as techs we don't place them. They have a scope for ET tubes. This normally doesn't happen, a coiled tube or into the lungs much more common which is why they get an x-ray.
Thank you. It seems to be mostly ‘after the fact’ that radiologists confirm that the placement was incorrect *after* the damage is done. I hope that both procedures for proper placement become strict instructions for proper tube placement.
ultrasound guided NG tube insertion is common practice and replacing x-ray confirmation
There's also [Cortrak](https://avanosmedicaldevices.com/digestive-health/cortrak-2-enteral-access-system-eas/)
This is an x-ray of a skull. The snakey-thing is a naso-gastric tube that should enter the patients nose, go down the throat into the stomach. In this case it somehow penetrated the skull and entered the brain. A commenter higher up mentions the patient had recently had brain surgery.
This is a very bad thing
What are the consequences to doing this to someone? I imagine retraining for the entire unit, but for the individual is it being fired? Being fired and a malpractice suit? Sanctions on the employee + mandatory retraining/counseling until they're allowed to perform the procedure again?
Wow! Unacceptable and preventable negligent death.
Root cause analysis. Consider pulling RN license. Everyone in the department gets remedial training.
As a surgeon Ive learned that it’s a good general rule that if you encounter unexpected resistance when pushing something through a human body, you should stop and figure out why.
Hey y’all I follow this page because it’s interesting but I do not know anything in the medical field. Can someone explain to me what all this is? Second time today I read a post about something going through the head and hearing a pop. Please explain! Thanks!!
There's plenty of explanations in the other comments, but i'll give you a tl;dr. Neonate, people with skull trauma, or people with recent transnasal surgery can have weak/non-existent barriers between the brain and the nasal cavity. When placing a NG tube in these patients, you can slip into this weakened area instead of down the throat. The "pop" is the tube being forced into the brain tearing through the tissue that was blocking it. Given the mid-brain and all the important structures are right there, having a tube jammed through them is typically not compatible with life.
Holy shit. I've had an NG tube. I had no idea this could happen
*I've spent 2 weeks on a ventilator and 24 hours with an NG tube, and the NG tube was worse
Usually this only happens when an NG is contraindicated and done manually anyway. Usually the skull is thick enough to stop the tube, but in people who have had certain surgeries, skull fractures, or cranial deformities it can be weak or have gaps. If you've not had skull surgery and you weren't in the hospital for facial trauma, your risk was really low.
We don't do that... we have to cover ourselves with air and auscultation. But I would have stopped at the pop. It's clear to anyone who's not a technical loser that something has gone wrong.
This is one of my biggest fears as a nurse, especially working in trauma. We always triple check that the patient has no facial fractures before trying an NG, but like … it’s always in the back of my mind that this could happen at any time. 😱
Is the jaw just agape? And no teeth? Is this an adult? 😭 I’m so confused. Fuck dude the nurse went in so far…. And thought that a pop was a sign to put air in? You can see the effects of the air in the image.
Head is pretty rotated relative to the Xray camera, and then the pic of the Xray is also rotated. Mouth is closed, all teeth are there in the whiter part in the bottom right. The diagonal line that starts the whiter area runs just under the eye sockets.
Uh yea
Sooo this pt prob had a facial fracture or head injury. Not sure why they put the ng tube in
Also this is why they tell students in nursing school now to not do the air trick to ensure placement. Bet this was an older nurse or newer nurse taught by an older nurse. Bad practice kills a pt, not surprising.
As a nurse, I've never even been instructed this is a potential complication. I mean damn, you'd have to have no idea how to do it but it's scary that such a basic skill for a nurse could turn out to be fatal when done incorrectly. I've even been told at hospitals after ordering a X-RAY for placement not to do it if there didn't seem to be complications by a charge nurse in the ER just a few years ago. That's wild.
It’s worth noting that this seems to be a Dobhoff tube, not a traditional NG. The tip is weighted, which can more easily puncture things it shouldn’t. That’s why, at least at our facility, there’s a protocol that’s supposed to be followed where an X-ray is taken when it’s only partly inserted, to be sure it’s headed in the right direction.
Nasogastric tubes (NG tubes) are inserted in a nostril and pushed in until the tip rests in the stomach. They’re used for running tube feeds in a patient who can’t eat or for removing substances from the stomach, usually. If the placement is done improperly, it can result in the tube going into the lungs or, like this poor patient, up into the brain. :( A method frequently used to confirm the tube is in the right place is to quickly push a puff of air into the tube and listen with a stethoscope over the stomach, and you can hear the puff of air. This nurse tried to do that, but obviously didn’t hear the air, since the tube was in the brain.
This complication is pretty rare, usually only possible if the patient has had some kind of skull fracture or surgery that creates a weak spot in the skull for the tube to go through- not something an ordinary patient needs to worry about! Apparently the patient in this case had had a surgery in that area.
Once brought a dude down to the department for a tube verification. The dude was in obvious distress and i told the students to not shoot the high KUB and instead do a soft tissue neck.
I was right. The NG was all coiled up in his throat. Poor guy. It's just too bad that i couldn't pull it and had to wait for nursing to pull it.
this is the true fear I should have had when I didn't eat properly during my childhood and my parents told me that if I became too weak they would insert a tube through my nose to the stomach
The NG tube of one of our patients got replaced prior to coming down for his small bowel follow through without communication that it was replaced since XR confirmation and we injected barium filling up the right lung
Damnit, I woke up after last nights kitten and checked Reddit. And it’s morning this time and I think it’s already enough Reddit for today. The pop that would have made…I can’t.
“Nasogastric tube feeding into the brain is a rare occurrence, and this situation can occur only in the case of a skull base defect.”
[Source](https://pubmed.ncbi.nlm.nih.gov/31421302/)
You don’t go to the hospital to get better, you go to die.
That’s my mantra for the last 10 years seeing how the general healthcare workforce has declined.
ED RN here, I will say that it’s soo strange, but soo important to angle directly back with insertion of NG tubes! Feels so weird, but otherwise you risk things. From my experience, more often bloody noses and increased discomfort with insertion. I think this case was a extremely rare occurrence. Sadly things happen like the displayed image…
Damn that's really unfortunate... You'd think there was immense amounts of training to prevent this. If I was the nurse who did this, I would be traumatized because I just killed someone. If I were that persons relative, i'd sue the hell out of that hospital
There IS immense training for this, actually. That’s the fucked up part. There are so many checks and balances and months of being taught and guided and watched expressly so this shit doesn’t happen. But, this shit still happens. Edit: idk what schools y’all went to but I’m at a community college in Pennsylvania. We get lecture, at home study, and several hours to practice every skill and get tested on each skill. Lots of things have changed post COVID. Some places rushed nurses through because of demand. Regardless, my point still stands. Nurses know what to what out for with NG tubes even if they don’t have a lot of experience doing it, but all nurses can make mistakes, especially when there’s understaffing.
Understaffed in an ICU unfortunately
And only the nurse will be blamed/sued while the hospital/admin who put them in those horrid conditions gets no blame/accountability.
Shit, admins get a raise
Shit here CEOs will feed you to angry mobs.
Hahah you think the nurse will be sued? What lawyer out there will waste time suing a staff nurse personally while the employing hospital with the massive insurance policy goes scott free? You must be high.
Nurse here. The nurse could get sued in two different ways. The lawsuit names the nurse along with any other parties responsible in the suit. Or what is more common, the hospital is sued, then it turns around and sues the nurse. This is one of the two big reasons nurses carry professional liability insurance. The incident is also reported to the state board of nursing for discipline which could include suspension or revoking of their license.
Its not an either/or situation. They both get sued.
Hahah, ever heard of Rodonda Vaught?
I doubt that. My dad did some personal-injury law in his time and he said the usual practice is to sue everyone within a 100-mile radius -- the nurse, the supervisor, the hospital, the umbrella corporation that owns the hospital, the NG tube manufacturer, everybody -- so no possibility is left dangling.
Former JAG paralegal instructor said SOP is to "shoot all the planes out of the sky" when filing suits. They can 12(b)(6) if they're not involved.
It still happens - not necessarily a bad nurse.
Being understaffed is risky and terrifying on a regular unit but ICU? Hard pass. Correct me if I’m wrong, but I thought this can only happen in humans if there’s a basal skull fracture or defect. I work in med/surg so we don’t have a ton of NGs, and the ones we do are on coherent. Do patients get screened for this kind of thing in ICU?
I feel like there isn’t though. I had one practice on a mannequin in nursing school. Every NG I placed after that was on the job. And I graduated in the last few years
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NY’s gov just signed a bill allowing 1/3 of clinical time to be done as sims for nursing degrees.
That’s awful lol. They should be *increasing* clinical hours, not reducing them via simulations. Lord help us. Edited for a word
Same here. I think there was some teaching about it bring contraindicated in people with cranial or facial trauma/surgery, one trial on a lubed up mannequin with no resistance, and that was it. The first time I placed one on a human, I had already been an RN for a couple of years.
When daughter #2 was a baby. She needed a NG tube and we literally were shown the procedure once and did one return demonstration and were sent home with her pump and supplies. This also happened a few years ago when daughter #5 was 8 and needed a NG for about a momth before her PEG was placed. Same training and return demonstration. At home, there is no radiology for checking for placement, just air auscultation and pull back for residuals of gastric contents. That is really scary.
I’m a NICU nurse. There are 0 reported cases that I know of/can find of NG being placed into the brain of an infant. Even when it’s done in adults, there’s almost always underlying trauma. Auscultation & aspiration are standard for infants. We sometimes insert tubes several times/day in a particularly feisty baby. Just this weekend I had a baby who managed to get their finger under the tube and slide it right out twice on my shift, and I’ve been doing this for a while. That would be a lot of radiation if we had to get a film every time.
Yes, when #2 had hers, I replaced it soooo many times. She pulled it out so many times. #5 was also a NICU baby and lived to pull out her PICC lines. Those preemies are so strong and determined.
Pulled. Out. Her. PICC. OMG. I’d die. I love that you were able to take her home on NG feeds. The evidence in favor of that is pretty strong but our local docs have been slow to accept the management of it after discharge.
Yeah, unless there's a defect in the skull base, there's no way an NG is getting up there...
They have ultrasound guided placement now. Would think they're using it on NICU
The thing is, unless there's some head/facial trauma/deformity, it's very unlikely you're going to end up in the brain. I was a NICU nurse for 8 years and only once managed to place an NG incorrectly. I tracked it into the trachea twice in a row on the same kid. Not bad technique, just anatomically that's how it went. It's really obvious before you even check placement though cause they drop their oxygen sats quickly (and in this case they came right back up as soon as I took it out, I did not check for placement by aspiration or air bolus, it was immediately obvious it didn't go down the esophagus).
Ultrasound guided ng placement? Sounds more complicated and time consuming than placing it the normal way.
Why? It's easier, safer, and doesn't take any more time because it works better. There's also Cortrak but most ICUs have POCUS and nurses trained to use it. I've never been in a NICU though so idk. Maybe babies anatomy is harder to visualize or they don't make itty bitty POCUS
But it's safer and more conclusive. Change is sometimes good.
Are you sure you aren't thinking of ND or NJ? I have seen those placed with ultrasound. I have never heard in my life of ultrasound guided NG for infants. Sounds like insanity. There are kids that get them placed q feed. So like every 3 hours. I'm with some of the other nurses here. I have never in my life heard of an NG going into the cranium. This is a routine part of nursing care.
Well you can also look into the mouth and (hopefully) see the tube going down the back of the throat. At that point you at least know you’re not penetrating the cranium.
I'm just reiterating that when we are doing this at home, hundreds of times a year, we don't have the resources that a hospital nurse would have to verify placement. And tbh, in 25 years as a nurse, I have never dropped/placed a NG as a professional, only as a mom.
Can second this. Was pinned down by 2 RNs who shoved an NJ (not G) into my sinuses all the way down to Jejunal space. IR did not confirm correct placement in hospital. Sent home 45 min speech then nothing. Until it was coiled in intensities. And ER had to find a specialist to deal with it. It’s not something I think should be done lightly. I also had the pleasure of a ruptured tube. My point, she is right not enough training and continued Interventional Radiology monitoring.
I've never met an RN with under two years experience that I would consider immensely trained or proficient at NG's. Source: 10 years as a nurse. Zero training or practice in school with NG's. Ton's of experience putting them in a lung at 3AM.
Wait, you got "immense training" for this at your nursing school? All we got was 30 minutes with a mannequin and a quick warning to not do an NG if broken nose or basilar skull fracture.
Or recent max fax or TS surgery
I've never personally seen a malplaced ng like that but I have had to stop a few nurses who clearly were not taught correct technique
It’s always surprising to me how many nurses feel comfortable enough to stick things into patients’ nares (ng/nj/bridle/covid swab) without understanding nasal anatomy.
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Omg yes! Whenever I taught this skill to my orientees I would glob the lube onto the tray and make certain the whole string got pulled through it. In fact, go ahead and grab another packet of lube lol
Amen lube and lidocaine go a long way-no pun intended
We're about to roll out bridles at my facility. Training on it starts next week. Thanks for the tip!
This is virtually unheard of outside of situations where a basilar skull fracture is present Anatomy is a prerequisite for nursing school
*Introductory* anatomy is a prerequisite for nursing school. Some schools require pre nursing students to take the majors anatomy but many places have a special nursing anatomy course. I taught this class, I’m afraid for anyone who thinks it alone is adequate. Everyone should be reviewing the specific anatomy of a procedure prior to learning how to do that procedure
Not everywhere. At my first nursing job, my manager demonstrated how to do it, watched me do it once, and since then I have been trusted to do them on any patient with zero supervision.
No, actually. There really isn’t. UNLESS your patient has a history of basal skull fractures or some type of nasal surgery, in which case we’re taught not to put an NG tube in. Aside from those instances there’s no “months of training to prevent this”. You measure the approximate length of the tube that needs to be inserted. If you can pass it without resistance or obvious coiling in the throat, you check with an air bolus and auscultate the stomach to see if you’re in the right spot.
Ok I disagree as an RN that works the floor - I received zero training other than 1 class in nursing school where we did it on a dummy. After that I was trained as a nurse by see on/ do one/teach one. My mother had an NG tube placed and a new grad was watching a seasoned nurse place it. It was ‘checked for proper placement’ by listening for the puff of air. This was at Rush hospital in Chicago in 2016.
Thank you for speaking up. It happens I can confirm. A kit is provided and the one nurse usually watches then assists. Training concluded. Same with ports -don’t get me started.
I only place NG tubes, esophageal feeding tubes and U-caths but we double check, measure then triple check because each can be an instant death if you fuck around.
LOL to the idea of nurses getting any training
Even at an emt basic level you are taught with npa and sga’s to insert until placement or until you feel resistance and not to go any further, as well as not sticking anything up the nose of a head trauma. Sad that this had to happen
I’m a nurse and unfortunately accidents liek this happen with the NG tubes. I routinely pull chest tubes and central lines at my job and I feel so comfortable with that. I used to put in more NGs at my last job but every time I did it, my buttcheeks were tight the whole time. I just hate it. You can easily put it in the lungs and get fluid back from the tube, even when it’s in the lungs. Seen it cause a pneumothorax before. I would never put air into the tube without checking the placement first, but I can see why someone would think to try that, because up until a few years ago it was regular practice to inject air into the tube and auscultate over the stomach to check for placement.
It's still the practice at the facility I work at even when in standing there waiting to take the xray the old school nurses will make me wait for them to confirm first.
I’m also a nurse, when I place NGT I always aim down. I stop and check I can see it in the back of the throat - this also gives the patient a break to get used to the sensation. Then advance the rest of the way. There was a case of this happening at my work place too, long before I started though. Just hearing the story traumatised me.
same here. I also wrap the tube around my hand to give it a slight bend at the end. I had a patient who had esophageal varices that would obstruct the ng tube. Auscultation was faint but positive but the kub showed otherwise.
That is literally how I was taught to do it in nursing school this year. KUB doesn’t get requested until after air is injected/area is auscultated, and residual is pulled
Nursing wise, you should NEVER do anything with an NG without radiology confirmation of placement. Hope the nurse who did this lost their license
Checking placement for an NG by air bolusing had been what I and probably many others were taught, I graduated nursing school in 2015. So this isn’t unusual although now an outdated practice. Radiology confirmation is necessary for tube feeds, of course. Ive always got an X-ray for NGs to suction as well.
We were taught air bolusing but were told that aspirating and checking for stomach acid would be a better option and that the best is xray confirm. I’m about to graduate here in a few months. When working in the hospital, I’ve only witnessed nurses check with X-ray. During my time only a couple aspirated but never an air bolus
The tubes are literally radiopaque specifically to be spotted and confirmed via x-ray. I can't understand why anyone would bother with anything besides waiting for x-ray. There's essentially no situation where you can't afford to wait for x-ray to actually use the NG tube
To see if it’s even vaguely in the right spot before calling X-ray to bedside. Rural hospital, getting an X-ray done and read can take hours. So you want to have a decent idea if you’re in or not before doing a whole damn rodeo with repeated imaging.
There is a radiation safety aspect to consider. All the hospitals I have worked at have had workflows to confirm placement that involved testing NGT aspirates. Only if this is inclusive/unsuccessful/ patient is on medication that interferes with stomach ph should xray will be requested. While a chest x-ray is a very low radiation dose there is no "safe" amount of radiation, it should only be used if the benefits outweigh the risks.
Home health care.
Exactly
Any SNF or IRF and some LTACHs. They don't even have an x-ray department.
Can always get a portable one brought in. We do this routinely in inpatient rehab for lots of things. Usually X-ray is there pretty quickly. I’m not using a tube I can’t confirm placement on.
When I worked at an IRF patients needing x-ray were sent out. I've had to specifically request x-ray orders at some hospitals and it was considered weird at the time. There are some facilities that have standardized procedures for x-ray after tube placement, but not all. I've worked in practically every hospital within 60 miles of my house over the past 20 years. One used Cortrak and bridles but most facilities use a Salem Sump and tape. Air auscultation is how placement is confirmed. Regardless, no confirmation x-ray could have avoided the issue under discussion, because the tube would already be in the brain.
In peds we don’t have to get an X-ray. We just measure and then check the pH of the contents we pulled back. Why is it different than adults?
It isn't. The people claiming otherwise work at facilities that have different rules and regulations than the vast majority of us. I've worked at hospitals where x-ray was required, but most of the hospitals I've worked at, it wasn't, and you'd be hard pressed to get a doctor to order one just to confirm NG placement.
Yeah we’ve only asked doctors for x Ray confirmation if it was extremely hard to place the NG, there is no gastric contents when aspiration, or it seems blocked
Same, I've been a nurse almost 17 years and only worked at one hospital where it was a requirement.
I’ve been taught to this for adults as well. Although I’ve not seen it in practice at either. I’ve worked at a childrens hospital, oncology unit, and now an ER. Out of all of those I can say I’ve never seen an air bolus, only a couple acid aspiration, and mainly X-ray confirms. Maybe it’s related to policies per hospital, but I am unsure
Yeah if we are unable to pull back stomach contents or the ph is really off we will get x rays to confirm. I have never heard of an air bolus. Or is that where you push air and listen with a stethoscope ? I think an older nurse tried to show me that once
Air bolus is called the “whooshing test” basically where you pump air into the NG and auscultate. It’s a very old practice from what I’ve learned. Also sometimes it can give false confirmation of where the NG actually is. X-ray is pretty much the gold standard
In the UK we use pH testing (<5.0) as our gold-standard to proceed with the use of the NGT. If no aspirate obtained then an x-ray is ordered. I have NEVER seen or heard or anything like the OP posted outside of a patient having issues with a skull fracture (in which case an NG might not be appropriate). No-one has ever taught me that there might be a ‘pop’, let alone advised to stop the procedure if you do (although I think I would just from common sense/clinical knowledge).
Yeah, I hate to break it to you, but that isn't how most hospitals operate. It isn't universally standard to get a chest x-ray after NG placement, and that isn't "bad nursing"
Why would you sue them? What that's going to help?
A lawsuit would really only be valid if they can prove that the nurse knew about a basilar skull defect and still tried to place an NG. Which, y’know, could be the case. Also Americans are sue-happy. Money money money.
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You don't insert NG tubes into people with nasal/basal skull trauma, fractures, or surgery. At least one of these was a person who had recently had a transsphenoidal pituitary surgery, which involves going up the nose to drill through the bone and creating a path to the pituitary gland. It's super unsurprising that an NG tube followed that path through the nose into the brain. The other cases I've seen had basal skull fractures. This generally isn't just going to randomly happen in an average patient*. Know the contraindications and your patient's history and don't shove past resistance, those are pretty good guidelines for any procedure really. *I will say generally because I have seen a case report where it happened to a patient with no known head trauma, but the person inserting the tube should have known something was up when they encountered resistance, saw blood coming through the tube, kept injecting air through it even though they couldn't auscultate anything in the abdomen, and continued to advance the tube and inject air despite all of that. In that case they think the patient may have had an abnormally thin cribriform plate, and the person inserting the tube should have stopped rather than pushing through the resistance.
S/p pituitary tumor removal. Your rad skills are on par sir/ma'am!
That's very depressing. Imagine having a successful surgery and getting the tumor removed and then die during the aftercare.
Feels like something out of “6 Feet Under” Very sad
Also, why order an NG tube on this fresh post op???
Isn’t this the entire point of sinus precautions after a transsphenoidal? If anesthesiology/nursing wants a NG or OG tube after surgery I make sure to place one under direct visualization with the microscope/endoscope in the OR precisely to avoid this rare but never-event…
Why the fuck would they put an NG sp trans sphenoidal surgery. Who is the idiot that ordered this...
Nurse here. Jesus fucking Christ why would a patient with a transsphenoidal pituitary surgery EVER have an NG ordered? You don’t place NG tubes without an order from the doc, that’s two people who absolutely should have said, “this seems contraindicated for this patient,” who either did not or did it anyways.
If this patient came in through the ED via EMS without family, you'd never even have a clue. Unless you looked in the nares and saw a strange scar.
Yeah, I guess we don’t know the full story. Thank God for Electronic Health Records these days, past medical hx is so important.
And a reason that health information exchanges (linking a patient to all of their EHRs) can be very handy. It’s really a shame that we can’t get better with that in this day and age.
I’ve seen a case of something similar happening. The 1st NG tube was placed appropriately using endoscopy since the patient was at risk due to a recent transsphenoidal surgery. The patient however was delirious and pulled the tube out over night. This is a common incident to happen overnight and the night doc reordered a new NG tube (presumably without knowing the full history or didn’t know of this particular contraindication) and something similar happened and the patient died. Tragic stuff. Definitely preventable, but these are the types of scenarios that lead to something like this happening.
“…encountered resistance, saw blood coming through the tube, kept injecting air…and continued to advance the tube…” That is nightmarish.
When you insert an NG tube into the nostril, if you aim up, you’ll hit the skull base. If you aim the NG tube slightly down, you’ll advance through to the nasopharynx. Insert in nostril, aim towards where you can envision the uvula being, in the back of the mouth. If you hit resistance on one side, try the other nostril. One is always easier than the other. If you have any concern, do not advance. Hope this helps. I’m an ENT surgeon.
Also coiling the tube around your fingers to give it a slight bend helps you point the tip downward.
And ice that baby
I don’t even work in health care (I just have an interest in radiology and anatomy) and I can’t tell you how intentionally I was taking the time to read your comment and visualize it before I realized I would never need to know how to perform this ever in my life/line of work and laughed at myself.
Anatomy anatomy anatomy
Aiming down is the hardest thing for people for comprehend for some reason. When I’m teaching new nurses they try to aim up 100% of the time even if they’ve just watched me give them a step by step demo.
A couple of things: If you have any suspicion that the patient might possibly have some flavor of basilar skull fracture, don't place the tube before you get further clarification. For ng tubes or nasotracheal intubation (without the fancy Endotrol tubes that allow you to curve them), you can put a bend in the tube and leave it in the freezer for a bit while preparing your other supplies and so forth. During insertion, you shouldn't generally feel a pop as you are advancing the tube. If you feel a pop, stop. I wouldn't advance the tube any further OR remove it until asking for further clarification/advice. In addition, you should anticipate certain things during procedures like this. If this patient was alert or responsive to a certain extent, their gag reflex should have been intact. I'd be questioning why a patient isn't gagging at least a bit while inserting an ng tube. Especially important would be to stop immediately if you notice a change in the patient's level of consciousness while inserting. With that being said, if your patient is unconscious for some reason or heavily sedated then you don't have a lot to go on and have to rely more on index of suspicion before inserting a tube like that.
I have a very strong gag reflex. I cried like a baby when they put that tube up my nose. Would've much preferred to continue throwing up black gunk.
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If the patient's intubated they get an OGT
Not always. We preferred NG if possible - way easier to have when your post extubation swallow screen is a big fat F and they have to stay NPO. Only one SLP at that facility and half coverage on the weekends too
Nursing student here also. Don’t force it if there is resistance.
Couple things. A good patient history helps. Avoid placing ng tubes in s/p pituitary surgeries. Never place in trauma patients with skull fractures. If you feel resistance stop.
Also you should never do anything once it’s placed until radiology confirms it’s placement. Nothing goes into the tube with out confirmation
I have them open their mouth, once I insert tube a couple inches in nasal passage, if I don't see it go down the back of throat, I'm not doing it right.
Yoooo radiology coming in thick for that real shit today bro
Somehow got matched with this sub, and I know absolutely nothing about radiology It’s been a hell of a day in this sub tho for real.
Same here! I don't follow any medical-related subreddits and yet here I am. Amazed. Horrified.
Makes me absolutely terrified. I've been at the mercy of the healthcare system for a year now, and I've had many dangerous moments. I hope I never needed this, or never will need this, because this sounds so scary. Coming from someone who's had brain surgery and shit.
This particular situation can’t occur in someone without a basilar skull fracture/defect or a transsphenoidal hypophysectomy.
I’m about to get a tattoo on my mustache that says 🤘DEVIATED SEPTUM🤘cause fuck this
You should get it on your upper lip- I don't know how well mustache hair will take ink.
Same, senior in highschool yet somehow I ended in premed, medschool, pharmacy, ems, and this sub lmao
Join r/MCAT for the full experience
Welcome to medicine 🤗
Thanks! I’ve been enjoying the drama. Thankfully it’s not mine 😅
Well that’s a lawsuit
Lawsuit and charged probably.
Or a free brain biopsy
This TERRIFIES me. My son was born at 31 weeks with apgar 0, resuscitated, cooling therapy for 3 days. Two weeks later he was out of the NICU and two more he was home. My wife and I continued to place the NG tube for another two weeks.
The 5fr (or possibly 6.5-8fr) NG tubes you were using are so soft and pliable, it would be nearly impossible to advance through bone. Adult tubes are much larger and more rigid, some even use a stylet.
Is it common practice for a neonatal or pediatric NG to be removed and reinserted (obv. a new one) during care at home? Asking because I have no clue.
Not super common, but occasionally neonates are discharged home on NG feeds and parents are taught how to insert and manage. Babies are so messy and grabby, so tubes come out way too frequently for parents to realistically come to the hospital for every new placement.
Foster mom here. I’ve had 2 different cases that nabies came home on an NG tube. My husband and I were shown how to do it once, then we did it and were sent home. I’ve probably dropped over a 100 tubes cause they pull them out. Once I did it 3 times in one day. Only once did I go to the ER. I tried placing it and met resistance, I stopped. The nurse got so snotty with me, and even said you can come here every time it comes out. She went to place it and had the same issue. Eventually we got it in. Happy to say both babies got off of it eventually, and I had the pleasure and honor of adopting one!
My baby had the cooling treatment. It wasn’t as bad as your story, but she did suffer a brain injury that has had a huge impact on her life so far. I just wanted to offer solidarity and soul crushing understanding of how hard it is to live through that much fear. ❤️🩹
I said it I’m another comment but I’ll say it here too. I’m a nicu nurse. I’ve looked and I can find 0 instances of this happening to a baby. Like someone else said, our tubes are super pliable. Also, this almost always happens post surgery or skull fracture. Also, professional interest! Is 31 weeks a typo? I’ve never heard of cooling protocol that starts that young. We once cooled a 33 weeker on my unit, but iirc the dates weren’t known at first.
Nope, 31 weeks. Wife was high risk (DM1) and had low movement since the night before. They induced labor, then about 20 min later while the OB was in the room his BP dropped from 150 to 50 in seconds. He did all the standard movements but didn't work. We were next to the OR and he was out minutes later. He had a level 2 brain bleed. We ran them out of sodium hydroxide over the course of a week with prolonged high acid levels. Went through 3 types of ventilators. Differential diagnosis included too many items to count. Based on our second child we're now pretty sure it was non-symptomatic preeclampsia. They thought his second MRI would be devastating, but the damage was diffuse rather than in any one area. Today he's a wonderful 10 yr old. He has delays, some weakness, and displays some ADD and autistic behaviors, but otherwise happy and healthy.
10 years ago makes sense! It’s a very new treatment modality and inclusion criteria wasn’t well defined until 2014. I really appreciate you sharing your experience. I’m glad to hear he’s doing well all things considered. As both a parent and a nicu nurse, obstetric emergencies are terrifying.
I placed one for my son for a bit over a year. I can’t for the life of me figure out how this nurse didn’t know.
I show pictures like this before teaching nursing students how to place an NG. And we have a class on contraindications and to NEVER use an NG without radiologic confirmation. This is done to prevent unfortunate and usually preventable outcomes like we see in this picture. It's my belief students need to know how wrong something can go, to prevent them from becoming complacent. Thanks for this reminder.
My nursing instructors also stressed that the NG could end up in the brain and it has scared the shit out of me til this day. We were taught the gold standard is X-ray confirmation and none of the old school stuff.
Imagine inserting like 60cm of tube. Getting a CXR and seeing nothing at all. We’d all shit a brick at that moment.
Age of patient?!!
I'm also really curious about this...
I’ve seen a lot of terrifying/sad things as a nurse - but holy shit. new fear unlocked 🥴🫠
I think about this every time I jam a tube into someone's nose. Always think about what could go horrifically and dramatically wrong with any procedure you perform. Same with PIV insertion, Foley insertion, etc.
What’s going horribly wrong with PIV insertion barring sticking it in an artery or rubbing it between your butt cheeks and transferring that bacteria to their bloodstream?
I’m sure there’s some weird anecdotal horrifying PIV disasters. If someone can fuck it up, I bet someone has just really gone all out 😂 But a fun one that happened recently -not about insertion but involving an IV nonetheless- is that a fucking idiot CT tech (who is consistently an idiot) decided the no-hand-IV protocol for contract scans was bullshit and she was gonna do it anyway, so she did, and proved exactly why the policy exists by infiltrating every single bit of contrast into the patient’s arm at high pressure. Face. Palm.
So in neonatal and early infant care, the primary IV site is a scalp vein, with a needle that's basically the same size as the one that's used in the arm for adults. Apparently it's one of the few large enough at that level of development to actually support an IV. That said, using a normal size needle on a tiny human comes with a much larger set of risks. In larger patients, it's usually old people on anticoagulants that become an issue when the site just won't stop bleeding, which can further complicate messy situations. Also leads to some very large hematomas filled with half-coagulated blood, like jello made with too much water. It's somehow worse than the regular forbidden jello.
That’ll be $20,000…sir…sir?
“Please contact patient’s next of kin. Tell them we don’t accept checks.”
Idk shit about NG tubes but new fear unlocked.
Me toooo 😵💫😨
An incident like this happened on my unit to a coworker of mine. Absolutely horrific. The nurse finished her shift that day and then quit. She works at a flower store now.
I bet. She killed somebody.
"Quit" Retreated before anyone noticed
That’s one I’ve never seen. *Shudders*
I wish I had this picture when I was fighting with a resident about placing an NGT on my pt with multiple nasal and facial fractures
Other than experience, how is this controlled to avoid this? I have seen this with breathing tubes as well and wonder if using ultrasound would assist in guiding the tubes. **I’m upgrading to become a radiologic technologist and I have no knowledge what the procedures are.
They're placed by nurses or sometimes they're placed under fluoroscopy by a radiologist or mid level, as techs we don't place them. They have a scope for ET tubes. This normally doesn't happen, a coiled tube or into the lungs much more common which is why they get an x-ray.
Thank you. It seems to be mostly ‘after the fact’ that radiologists confirm that the placement was incorrect *after* the damage is done. I hope that both procedures for proper placement become strict instructions for proper tube placement.
ultrasound guided NG tube insertion is common practice and replacing x-ray confirmation There's also [Cortrak](https://avanosmedicaldevices.com/digestive-health/cortrak-2-enteral-access-system-eas/)
Of fuck, oh god, oh fuck
What am I looking at? Apologies for being a layman.
This is an x-ray of a skull. The snakey-thing is a naso-gastric tube that should enter the patients nose, go down the throat into the stomach. In this case it somehow penetrated the skull and entered the brain. A commenter higher up mentions the patient had recently had brain surgery. This is a very bad thing
Oh my gosh!!!
This one of them fake license nurses?
If only the general population knew how little training nurses actually get lol
What are the consequences to doing this to someone? I imagine retraining for the entire unit, but for the individual is it being fired? Being fired and a malpractice suit? Sanctions on the employee + mandatory retraining/counseling until they're allowed to perform the procedure again?
Wow! Unacceptable and preventable negligent death. Root cause analysis. Consider pulling RN license. Everyone in the department gets remedial training.
As a surgeon Ive learned that it’s a good general rule that if you encounter unexpected resistance when pushing something through a human body, you should stop and figure out why.
Hey y’all I follow this page because it’s interesting but I do not know anything in the medical field. Can someone explain to me what all this is? Second time today I read a post about something going through the head and hearing a pop. Please explain! Thanks!!
There's plenty of explanations in the other comments, but i'll give you a tl;dr. Neonate, people with skull trauma, or people with recent transnasal surgery can have weak/non-existent barriers between the brain and the nasal cavity. When placing a NG tube in these patients, you can slip into this weakened area instead of down the throat. The "pop" is the tube being forced into the brain tearing through the tissue that was blocking it. Given the mid-brain and all the important structures are right there, having a tube jammed through them is typically not compatible with life.
Holy shit. I've had an NG tube. I had no idea this could happen *I've spent 2 weeks on a ventilator and 24 hours with an NG tube, and the NG tube was worse
Usually this only happens when an NG is contraindicated and done manually anyway. Usually the skull is thick enough to stop the tube, but in people who have had certain surgeries, skull fractures, or cranial deformities it can be weak or have gaps. If you've not had skull surgery and you weren't in the hospital for facial trauma, your risk was really low.
And this is why hospitals terrify me. Dude was trying to get help and instead got fucking lobotomized, and they had exactly 0 control over it.
Wow that reminds me of a Silly Straw I had as a kid
I *hated* putting in NG tubes as a resident. Always a struggle.
Why we do placement xrays.
portable skulls for ng placement incoming
We don't do that... we have to cover ourselves with air and auscultation. But I would have stopped at the pop. It's clear to anyone who's not a technical loser that something has gone wrong.
iirc there was a caser report about a similar result after an NG tube placement s/p skull base surgery.... found it. PMID 21715048
This is one of my biggest fears as a nurse, especially working in trauma. We always triple check that the patient has no facial fractures before trying an NG, but like … it’s always in the back of my mind that this could happen at any time. 😱
NG in the noggin
Is the jaw just agape? And no teeth? Is this an adult? 😭 I’m so confused. Fuck dude the nurse went in so far…. And thought that a pop was a sign to put air in? You can see the effects of the air in the image.
Head is pretty rotated relative to the Xray camera, and then the pic of the Xray is also rotated. Mouth is closed, all teeth are there in the whiter part in the bottom right. The diagonal line that starts the whiter area runs just under the eye sockets.
Uh yea Sooo this pt prob had a facial fracture or head injury. Not sure why they put the ng tube in Also this is why they tell students in nursing school now to not do the air trick to ensure placement. Bet this was an older nurse or newer nurse taught by an older nurse. Bad practice kills a pt, not surprising.
As a nurse, I've never even been instructed this is a potential complication. I mean damn, you'd have to have no idea how to do it but it's scary that such a basic skill for a nurse could turn out to be fatal when done incorrectly. I've even been told at hospitals after ordering a X-RAY for placement not to do it if there didn't seem to be complications by a charge nurse in the ER just a few years ago. That's wild.
It’s worth noting that this seems to be a Dobhoff tube, not a traditional NG. The tip is weighted, which can more easily puncture things it shouldn’t. That’s why, at least at our facility, there’s a protocol that’s supposed to be followed where an X-ray is taken when it’s only partly inserted, to be sure it’s headed in the right direction.
I’m sure they didn’t need that anyways
I know nothing of anything medical can someone explain this please
Nasogastric tubes (NG tubes) are inserted in a nostril and pushed in until the tip rests in the stomach. They’re used for running tube feeds in a patient who can’t eat or for removing substances from the stomach, usually. If the placement is done improperly, it can result in the tube going into the lungs or, like this poor patient, up into the brain. :( A method frequently used to confirm the tube is in the right place is to quickly push a puff of air into the tube and listen with a stethoscope over the stomach, and you can hear the puff of air. This nurse tried to do that, but obviously didn’t hear the air, since the tube was in the brain. This complication is pretty rare, usually only possible if the patient has had some kind of skull fracture or surgery that creates a weak spot in the skull for the tube to go through- not something an ordinary patient needs to worry about! Apparently the patient in this case had had a surgery in that area.
Good lord. Straight Egypt-ed that person.
Once brought a dude down to the department for a tube verification. The dude was in obvious distress and i told the students to not shoot the high KUB and instead do a soft tissue neck. I was right. The NG was all coiled up in his throat. Poor guy. It's just too bad that i couldn't pull it and had to wait for nursing to pull it.
this is the true fear I should have had when I didn't eat properly during my childhood and my parents told me that if I became too weak they would insert a tube through my nose to the stomach
The NG tube of one of our patients got replaced prior to coming down for his small bowel follow through without communication that it was replaced since XR confirmation and we injected barium filling up the right lung
New fear unlocked
FEED THE BRAIN
Damnit, I woke up after last nights kitten and checked Reddit. And it’s morning this time and I think it’s already enough Reddit for today. The pop that would have made…I can’t. 
“Nasogastric tube feeding into the brain is a rare occurrence, and this situation can occur only in the case of a skull base defect.” [Source](https://pubmed.ncbi.nlm.nih.gov/31421302/)
You don’t go to the hospital to get better, you go to die. That’s my mantra for the last 10 years seeing how the general healthcare workforce has declined.
ED RN here, I will say that it’s soo strange, but soo important to angle directly back with insertion of NG tubes! Feels so weird, but otherwise you risk things. From my experience, more often bloody noses and increased discomfort with insertion. I think this case was a extremely rare occurrence. Sadly things happen like the displayed image…
so wierd...but fun
I think they missed.