I had been asked to pass the nasogastric tube, a task I hadn’t previously undertaken. It was a procedure that the nurses normally performed. However, I didn’t anticipate any difficulties. At any one time on the surgical ward, there were at least half a dozen patients being treated with these tubes and I wasn’t aware that the nurses had any difficulty in putting them into place.
The tube is passed through the nose into the back of the mouth then down the gullet such that it’s tip comes to rest in the stomach. It is made of plastic, is transparent, about 50 centimetres long, with a diameter about that of a drinking straw. The tube allows gastric juices to be aspirated, keeping the stomach empty in the early days after an operation.
Taking the tube out of its plastic bag, I fed it gently into Mr Quigley’s left nostril. It went in about half an inch and then hit a blockage. I withdrew it and tried again, this time pushing a little more firmly but again it came to a full stop, suggesting that it had reached a fairly solid obstruction. Once more, I was forced to take it out and wondered whether at some time he had broken his nose and that the channel up the nostril had been narrowed or deformed as a result.
“Let’s try the other side,” I said.
As on the left, the tube seemed to meet some resistance inside the nose but this time by pushing a little harder the tube advanced and I made good progress. Suddenly, Mr Quigley, winced apparently in some discomfort and his hand went to his nose.
“Don’t worry,” I said, using my most soothing voice and gently guiding his hand back to his side, “we are getting somewhere now”.
As I pushed more and more of the tube up his nose, Mr Quigley became progressively alarmed. He became unable to speak and pointed anxiously to his cheeks, both of which were now swollen like hamster’s pouches. Then, quite suddenly, in front of my eyes, the tip of the plastic tube emerged like a viper’s tongue from between his lips. He opened his mouth and easily visible inside, were 20 inches of plastic tube, all coiled, twisted and buckled. Clearly the tube had not been going down the gullet to the stomach at all; it had taken a wrong turn at the back of the mouth! What was I to do?
I was tempted to ask him to spit it out, through his mouth, hoping that the whole tube, including the last few inches that were still dangling from his nose would follow. The tube however was much wider at the top and it seemed unlikely that it would pass down through the nose. The only alternative was to pull the tube backwards, up through the nose and hope and pray that it wouldn’t tie itself in a knot somewhere at the back of the throat as invariably happens whenever I handle plastic coated electrical cabling or a plastic hosepipe. If that happened, it might be impossible to remove the tube either upwards or downwards and the patient might have to go back to the operating theatre to have it retrieved! I felt a cold sweat on the back of my neck. Why on earth hadn’t I been wise enough to ask for some advice?
X-ray of ‘knotted’ nasogastric tube in pharynx
Fortunately not this patient!!
Deciding that withdrawing it through the nose was probably the better option, I slowly and carefully started to pull the tube upwards. To my great relief, the hampster’s pouches gradually decreased in size, the viper’s tongue disappeared and the tube came out without undue difficulty. A wave of relief swept through me as I realised that although I had caused some temporary distress to the patient no serious harm had resulted. Next time, I thought, I will be sensible and get some help but as it happened, stupidly, I didn’t seek advice which was to cause both Mr Quigley and me considerable distress as will be explained in the next post
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This story is adapted from ‘THE FIRST CUT’ which tells the story of a newly qualified doctor’s first six months working on a surgical unit. It is available from Amazon as a paperback or ebook.
Thought for the day
Waiter delivering champagne to George Best’s hotel room: ‘Tell me Mr Best, where did it all go wrong?’
£20,00 in cash was scattered on the bed, which also contained Miss World.
Anonymous: attributed.
Extract from a Doctor’s letter; This patient with vascular disease has angina and intermittent fornication when walking!