In a few weeks, the Australian College of Rural and Remote Medicine will hold their annual conference in Cairns. Part of this gathering is an online competition involving making a quick one minute refresher video on an aspect of medical care. JAMIT or Just A Minute Instant Tutorial has the potential of reminding clinicians about the basics of a procedure if they havent performed it in a while.
My contribution is a quick update on nasogastric tube insertion. Below are some extended tips for those wanting more information. These tips can also be used by medical students and junior doctors doing terms in emergency medicine and/or surgery. Enjoy!
- Gastric decompression – SBO
- GI imaging
- Feeding – choking risk
- Removing toxic substances
- Severe mid face trauma
- Recent nasal trauma or surgery
- Base of skull fracture
- Oesophageal varices
- NG tube (put in fridge if too bendy)
- Nasal spray
- Water with straw
- Lubrication gel
- 60ml syringe, litmus paper
- Tape, pin
- Drainage bag
- Explain procedure, need good bedside manner, build rapport
- Risks/benefits (sore throat, blood nose, sinusitis, oesophageal perforation, collapsed lung), (prevention of aspiration, nausea)
- Pick the most patent nostril and spray with lignocaine
- Measure length from tip of nose to left costal margin
- Sit upright, mild flexion of neck, hold back of head gently
- Assistant/patient hold water cup
- Lubricate and advance along the floor of the nose, twist tube as advances
- 10-20cm resistance, start sipping water, swallow tube down
- Encourage as tube passes “sip, sip, sip” “keep going” “you’re doing well”
- When to stop: cough, cant speak, nasal haemorrhage
- Check placement: blow air and auscultate, pH, CXR
- Tape to nose, pin to hospital gown
- Cepacol lozenges if throat sore
Delivered on the 16th August to the 2013 NRHSN NextGen conference. Only went over time by 3 mins….
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Talking to future country doctors, nurses and allied health providers about rural GP work, communication skills, teaching and family at the National Rural Health Student Network conference.
A few weeks ago, I was working an after hours GP shift at a ‘country’ hospital. I say this in inverted commas as it is only about 30-40 minutes drive to the city. The shift itself present relatively few challenges with a mixture of chest pains, general GP type presentations and some virally kids. At about 9:30pm, I was asked by the ward nurses to come and help with a patient who was getting agitated. Once this was sorted, one of the other nurses asked me to check on a patient down the corridor and replace her IV line. From the notes, the lady in her late 80s had been admitted that afternoon by her regular GP from his rooms. Given the severity of the illness, the GP had requested that the ambulance service take her from the rooms straight to a major hospital in the city. However from the ambulance crew note, it was evident that they had decided to bring her to the country hospital instead stating that going to the city hospital was “too harsh for her.” According to the GP notes, she was living at home with her daughter and independent in her ADLs. Evidently, she was quite a prim and proper lady who certainly wasn’t loaded with co-morbidities. The GP had documented some agitation, chills and that the patient was uncomfortable. He had sent off urine and bloods, but no CXR. The nurses were worried that she had deterioated and was now complaining of central chest/epigastric pain.
When I stepped into the room, this lady looked sick. Her respiratory rate was 40, pulse 94 and was sweaty and writhing in pain. The little voice in my head said “Gerry, she doesn’t belong here.” Its funny how that immediate reaction comes before any rational thoughts. But I thought through the scenario sitting back at the nurses station. Here were some of those thoughts:
- going home from my GP clinic shift in just over an hour
- two nurses on overnight for 30 inpatients
- limited access to radiology
- no monitoring available
- Usually a well lady, independent
So weighing it all up and putting it through the ‘grandparent-o-scope’ (what would I want done or do if this was my grandparent), I decided that she needed transfer to the city. Granted, this was the place that her GP originally wanted her to go. Muscle memory from working 6 hours from the city in Wudinna helped me dial the number in less than a second and I asked to be put through to the ED consultant. In the back of my mind were the handover calls that I had made from Wudinna. This is how the conversation went, I have changed the names and my parts are in bold:
ED: “Hoshsjs Ropsjnskss (unintelligible)”
GC: “Sorry, who am I speaking to?”
“Trevor Jones, ED”
“G’day Trevor, I’m Gerry a GP working up at Woopty Doo tonight. I have a quite a sick 87 yo lady I’d like to transfer down to you”
“We’re really busy here tonight”
“I understand, but I’d like to send her as I’m not at the hospital for much longer and I think she needs more care than we can provide. She was admitted by her GP for a suspected infection today, bloods and urine are still being processed. I havent got a CXR to look at but her lungs sounds pretty cruddy. She is breathing up to 40/min, temp is 38.9 and her BP is 196/88. Im wondering that she has a pneumonia or pyelonephritis.”
“Well, look you have the same antibiotics as us and we are really busy.”
“So you’re saying you want her to stay here? I havent got access to a CXR at this time and Im not here over night, Im a bit worried about this patient given her vitals.”
“What does her chest sound like?”
“There are some coarse creps in the bases”
“Well she might have a pneumonia…”
“Thats what Im worried about. Also I was wondering about some advice for her pain. She is quite distressed and I thought perhaps some morphine IV”
“That might stop her breathing”
“Ok, well maybe I’ll start with something oral to see…<click>”
Hung up. Just like that. No extra advice, no ‘ok then well send her down,’ nothing. Just click and the conversation had ended. Sod it. So I sat down and wrote up a quick review/transfer note and waited for the ambulance crew to arrive as I had already asked for them prior to the call! It was an intensive care paramedic that rocked up and we talked through the case. He was suprised by the decision by the previous crew to change the destination earlier in the day and agreed that this lady did not belong in this hospital. We got and ECG off, placed a new cannula in her and got her on her way.
Two days later I was able to drop past the city hospital ward the patient was on and had a chat with the CNC about her and the ED rudeness. The patient ended up having a nasty pyelonephritis and needed a few days of IV antibiotics. The CNC said that often the ED guys don’t understand where you are calling from and what resources you do and don’t have. Working in Wudinna last year, I could understand that clearly. But even close to the city, there are times when more intensive observation and care is needed. Unfortunately, the closer you are to the city, the more blurred the distinction becomes. People assume that you have a dedicated medical team overnight and 24 hour access to radiology and pathology. Im also getting a bit tired of the line “we’re really busy tonight” or “the ambulances are ramping” like that is going to change the outcome for the sick patient. True, it might be just a cry for acknowledgement that things are going crazy in their department, but what is it supposed to make me feel? Guilty for transferring someone who needs more care? Not a great place to put a country doctor in.
“we’re really busy tonight”
For me, the most disappointing part of the interaction was the rudeness to a fellow colleague asking for help. If you are 30 mins or 6 hours away, politeness shouldn’t change. And having worked in a city ED, I completely understand how busy they can get and how you end up trying to reduce the patient load as much as possible. But we are all in this game together. Often, I found the referrals from rural GPs to ED were great as they had been worked up with pathology sent, analgesia on board and IDC and IV lines in.
It is a shame that as a future rural GP, this has been a common experience when speaking to EDs in the city. Perhaps next time I won’t give a courtsey call and just let the patient rock up on the doorstep in an ambulance. But I believe in a handover and perfer not to be yelled at or hung up on. It made me think of this interaction that Tim Leeuwenburg had recently. So ED docs out there, think of us GPs in small hospitals without the luxuries that you may enjoy. We are transferring you the patient for a reason. Not because we want to avoid work, but for the patients best care. If we are sending them to you, it is because they need care greater than the level we can provide.
Rural GPs admit to our hospitals or discharge from clinic a lot of patients that might otherwise need transfer to the city. So be nice to us, because we could send a WHOLE lot more work if we wanted to!
22 year old male from small country town. No family history of cardiac disease. PMHx: anxiety started 6 months ago associated with some lightheadedness, hyperventilation. Non-smoker/drinker. 8 months ago, stopped using amphetamines and marijuana. Presented this time with chest discomfort radiating to epigastrium and back, came on at rest. BP 110/60, chest clear, HS dual + nil. Electrolytes (Mg, Ca) normal, TFTs normal, TropT negative at time of presentation and 24 hours later (not sure how it related to pain onset, I assume pain was close to time of presentation).
ECG 1 (sorry about the quality)
ECG 2 (24 hours later)
Further history or examination?
At some of the conferences I have been to recently (Breathing New Life, National Rural Health Alliance and Primary Health Care Research), there have been many amazing plenaries, symposia and presentations. What *has* been lackluster at the end of these sessions are the questions (or more often than not, disguised comments) posed from the audience. Many of us practice the art of public speaking for the delivery of talks, presentations etc, but how much time do we spend practicing to ask questions. From the quality of some that I have heard at the above conferences, not a great deal. So the following is a quick and handy reference on good question/comment etiquette to be used at any sort of conference or speech. I’m very happy to hear your thoughts and can add them to the list if there are any more gems.
Stand up (if you are able)
Sometimes in a big theatre or hall, it helps for the presenter and the audience to see who is talking. We are visual beings and usually like to see who is asking the question.
Often a person will stand up and try to talk into the microphone and its not on. This is usually because the sound person hasn’t had time to fade up the right microphone. Unfortunately then the person will fiddle with the settings at the bottom and turn the mic off. Just be patient and wait for the sound to come on. Also when talking into the microphone, speak clearly and slowly, hold it a few inches away from your mouth, not too far away.
It really helps the presenter and audience to know who you are and your background as it helps frame the question you are asking. For example: “I’m Gerry, a rural GP registrar from South Australia.”
Thank the presenter (if appropriate!)
If you enjoyed the talk and you are asking a question, why not give them some quick feedback? Of course if you didn’t like the talk you don’t have to congratulate them, nor do you need to tell them how bad it was! For example: “Hi, I’m Gerry, a rural GP registrar from South Australia. Thanks for your talk about knitting Dave, its an important area for our patients. My question is about….”
Comment vs. question
Sometimes when you stand up, it won’t be to ask a question. It will be to make a comment or observation. That’s fine, but just remember to state that. For example: “Thanks for your talk about baby llamas, I found it very enlightening. Now this is more of a comment, but I’ve found that they are also very cute.”
Keep it simple
Multiple part questions will only confuse the presenter, annoy the audience and make you look silly. Long, vague questions are difficult for the presenter to answer and won’t help the discussion. If you must ask more than one question, make sure you sign post them. For example: “My first question is about the use of ketamine in sedation of kids, how do you dose it. And secondly what other alternatives are there?”
No more than 15-20 seconds
Its a similar point to the point above, but don’t ramble on. The presenter and audience will lose focus if it isn’t quick and to the point. A good trick for a question that might be a bit complex is to draft it on a piece of paper. You will see some people on Q&A do this and those questions always come across really well.
Now your turn! If there are any more ideas, please post them in the comments below.