Post 33 Never assume that because you are a doctor you know better then the nurse

My unfortunate patient, Mr Quigley, was already distressed and when I suggested a second attempt to pass the nasogastric tube  into his stomach he looked concerned.   I’d already made one ill-judged attempt but the entire length of the tube had coiled inside his mouth making his face inflate like hamster’s cheek pouches!    Fortunately Mr Quigley didn’t seem to realise that this was the first time I had ever undertaken this procedure.

I apologised, gave him gave him a couple of minutes to recover, then tried again.  Gently I eased about 4 inches into his nose, then stopped and looked in his mouth.   Great; the tube was nowhere to be seen.  I advanced another inch, re-inspected the mouth and again was delighted there was still no sign of the tube.  I relaxed; the tip of the tube must now be safely in the gullet.   I pushed another two inches up the nose with renewed confidence.

 Suddenly, and without any warning, Mr Quigley’s hands grasped desperately at this throat as he gasped for breath.  He started a paroxysm of coughing and his cheeks took on an ominous purple hue.  He tried to speak but without breath was unable to do so.  There was a wild fear in his eyes.  Instantly, I knew what was amiss; the tube had not gone down the gullet but instead had gone down ‘the wrong way’ and was stuck in his windpipe blocking his airway.

At once I pulled the entire tube out but Mr Quigley was in fear for his life. He gasped for breath, making a high pitched wheezing sound, his eyes watered,  he coughed repeatedly, but fortunately, although it took several minutes, his breathing gradually returned to normal and he regained his composure.  Putting a reassuring arm around his shoulders, I apologise profusely for causing him so much anxiety and discomfort.

                                                             X-ray of patient whose tube had been passed under anaesthesia and entered his lung.

“Don’t worry Doctor,” he said when eventually he regained
enough breath to speak, “It’s me that’s being a nuisance. You’ve got your job to do.   We’ll try again but for God’s sake, give me a moment or two to catch my breath.”   He seemed to think the problem was his fault whereas I was certain it was due to my inexperience.

I wondered whether this was an appropriate time to call for assistance.  I’d been told repeatedly during my training that if junior doctors met any difficulties or were uncertain how to proceed they should call for help. Failing to call for help when it was required, they insisted, was a greater sin than calling unnecessarily.  Certainly, I was having difficulty but surely passing this wretched tube wasn’t such a difficult job.  After all, it was something the nurses did, day in and day out.  And I was damned if I was going to lose face by asking them for their assistance.

Whilst I was considering what to do, I received some encouragement from Mr Quigley.

 “Come on Doctor,” he said, “let’s get it over.”

With the benefit of hindsight, I know I should have called for assistance. The ‘retrospectoscope’ is the greatest of all medical instruments, but foolishly, I didn’t!    And so it was that with considerable trepidation I continued.  Approximately six inches of tube disappeared up the nose before the disaster happened.
  Mr Quigley was sitting up in his bed and I was standing about 12 inches away, immediately in front of him.  Without warning and accompanied by a loud retching noise, he vomited.   A pint and a half of stale blood mixed with yellowy-green bile hit me in the middle of the chest.   Involuntarily I took a step back.   Within a few seconds, a second vomit occurred, this time landing on my shoes, on the ward floor but also splashing beyond the confines of the screens that surrounded the bed.   In a flash, Sister Ashbrook appeared.   She assessed the situation instantly; the patient still retching, a pool of blood and bile on the floor and me, still holding the nasogastric tube in my hand, with the patient’s vomitus down the front of my white coat dripping onto my shoes.

 Sister turned to the student nurse who accompanied her.

  “Nurse Meredith,” she said, “please show Doctor Lambert the correct way to pass a nasogastric tube and then clear up this unholy mess.”

Was it my imagination or was there the slightest emphasis on the word ‘Doctor’ and the word ‘correct’?  Then ‘tutting’ loudly, with eyes to the ceiling and a sad shake of her head, she turned on her heels and left.

Nurse Meredith's first concern was the patient.
"I'm so sorry you've been sick," she said, her voice calm and sympathetic.   "Let's start by rinsing out your mouth."
Within a few minutes she had calmed the patient, washed his face and put him at his ease. Then she passed the nasogastric tube in a reassuring, skilful and professional manner.

The whole episode had taken about 20 seconds, had been painless and quite effortless.  Nurse Meredith busied herself anchoring the tube to the patient’s nose then looked across at me.  For a second our eyes met and in that moment I saw sympathy and understanding.   My heart missed a beat.

“It’s Dr Lambert isn’t it?” she said, a soft smile warming her face.  “I’m pleased to meet you.” 

I was ashamed, humiliated and, frankly, felt a complete fool.

“Thank you,” I said, “and thanks for showing me how to pass the tube. I’m afraid we weren’t shown how to do that at Medical School.” 

She looked me up and down, her eyes passing from my red face, to my soiled white coat then to the vomit on my shoes. Her eyes twinkled and again she smiled, now looking slightly amused. 

“Now what are we going to do with you?”

This was a question that was already worrying me.   I didn’t relish the prospect of walking through the ward in my present state, passing Sister Ashbrook on the way and then walking along the hospital corridors to my room though I was sure that Sister would have enjoyed the sight.

“You stay here for a minute while I slip and get another white coat for you from the linen cupboard,” she continued.  “I need to bring back some sheets to freshen up this bed as well.”

When she returned she had actually hidden the white coat amongst the sheets and pillowcases she had brought.  Behind the patient’s screen, I changed my coat and used the old one to wipe down my shoes. 

“That’s made you look a little more respectable, Dr Lambert,” my saviour said, now smiling broadly, “but you really don’t smell too good.  You slip away and change your shirt while I tidy up here.  I’ll get one of the other nurses to help me”.

“Thank you,” I said, “you’ve been extremely kind to a doctor in distress.”

Severely chastened, I left and managed to escape from the ward and reach my room without attracting too much attention.   I realised how foolish I’d been and in my heart knew that being publicly humiliated was my just reward. There was a lesson for me to learn here. When you don’t know what to do - don’t be too proud to ask for some advice. And don’t assume that because you’re a doctor you know better than the nurses!

This story is adapted from ‘THE FIRST CUT’ which is available from Amazon as a paperback or ebook.

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Thought for the day

Hindsight is always twenty-twenty vision    Billy Wilder 1906 -2002    

  Extract from doctor’s letter:  Healthy appearing decrepit 69 year old male; mentally alert but forgetful.    


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