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
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!
For the past 4 months I have been tutoring medical students in both Year 1 clinical skills and Year 3 case based learning. Before this, colleagues had always said that you learn so much from students. I have found this to be very true. It has also been a great way to look my own consulting and examination skills and find areas for improvement. Here is a short list (that will hopefully grow) of things that I have taught, I have learnt and that bring a smile to my face. If you are a clinician, I highly recommend doing teaching of some sort.
- Avoid negative leading questions “you havent been febrile have you?” It leads the patient to an answer, I’m guilty of it sometimes too!
- If after your beautiful open question the patient says “I have a cough.” Instead of jumping in to closed questions, ask another open question like “tell me more about the cough…”
- Explain examination procedures to patients in simple terms. So instead of saying “I’m going to percuss the lower lung fields,” you can say “Im just going to tap on your chest quickly.”
- If you state the absence of esoteric signs (Janeway lesions), be prepared to explain what they are a sign of
- To save you time listening to the chest say to the patient “take a big deep breath in and out through your mouth everytime you feel the stethoscope on your back
- Its called a ‘tongue depressor’ not ‘suppressor’!
- Avoid saying “cool” or “excellent” when asking history. It’s good that you have got the information, but it doesn’t sound great if they’ve just told you about their bowel cancer. Say “ok” or “mmhm.’
- Don’t pronounce the ‘p’ in ptosis
- Pt: “I havent seen a GP in 35 years.” Student: “Well its good that you came to see us today.” Great line
- Recap your history at the end. It gives yourself some time to remember any points you might have forgotten, the patient might remember something and it shows you’ve been listening!
- If a patient says they are not smoking, make sure you ask if they have every smoked.
- Similarly if you ask about recreational drugs, it’s a good idea to list some common examples.
- Be non-judgmental about any answer that comes back.
- Don’t be afraid of silence. In fact if there is a large pause, let the patient break it.
A few weeks ago, my uni students were given a scenario similar to this one:
Mr Hugh Jass, 65 year old lawyer presents with headache, nausea and sweatiness. Cough, non productive. Muscle aches, dysuria and urinary frequency. No symptoms of meningism. 25 year pack history. No other relevant family or past history.
O/E: Temp 40C, HR 90, BP 110/90, RR 18. Crackles in right base. Abdo tender suprpubically, no loin tenderness. BS normal.
In the case, Hugh is referred to a tertiary ED where he has some tests. CXR shows some COPD but no consolidation and urine grows E.coli. He is evenutally seen by a urology consultant who gets a better LUTS history and does the PR and PSA test.
The question was asked, quite fairly, should we have done a PR earlier? And if so, when? GP room, first ED work up? It made me wonder “would I have done a PR in the GP room for this man?”
I also put myself out on a limb during the case conference with the other tutors and said that I probably wouldn’t have sent this man to ED. Was almost shouted down! I thought that a reasonable action (even in the peri-urban setting) may have been to check for UTI with dipstick and commence on oral antibiotics. Given his high fever and symptoms perhaps even a shot of IV antibiotics as a stat dose? Although I understand that a UTI in a male is a concern, I thought immediate referral to ED was a tad overzealous. Of course more detailed history about urinary symptoms, DRE, PSA (if symptomatic) and a referral to urology would be on the cards, but within a week or so. It seemed from the other tutors that this would be too gung-ho….
Interested for your thoughts.
I have a favourite black jumper. In fact, its helping me write this post at this moment. Everyone has an item of clothing just like it. Unfortunately, the price paid is increased wear and tear. My black jumper started to develop a large hole under the armpit area at the start of last year. The nurses in Wudinna would give me grief when I started wearing it in the winter (sometimes for the cold, other times to disguise a non-ironed shirt…)
Eventually, enough nurses, family members and people on the street convinced me to get it repaired. Some said take it to a shop and other offered to stitch it up themselves. After politely declining on a few occasions, I found the opportunity to repair my old friend on a recent trip to Melbourne. Mum provided the obligatory box of needles, thread and scissors. But I had never fixed up any sort of material damage before, the only relevant word I knew was ‘darning’ from Elenor Rigby by The Beatles.
But the truth was I had done something like this, in fact I would do it once or twice a week. Often patients would present to the clinic with large cuts and lacerations and need stitching. Surely I could use these skills here? During a medical student and intern placement in country South Australia, I learnt a number of tips and tricks for suturing. In Jamestown, a pulley type horizontal mattress and running subcuticular stitches were taught to me by the great GPs there. To finish off each run of suture, I managed to remember how to do a hand tie. Amazing what can come back to you after three years!
So away the stitches went attempting to close the large axillary dehisence in my jumper. One aspect that was different was having to thread the cotton through the needle tip. That took steady hands and a large amount of accomodation (see cross-eyed picture above). Luckily I avoided any needle stick injuries as the material edges started to oppose. It probably took me 3 times longer than stitching up skin, but I eventually finished. And I can report that there has been no further wound separation since!
Has anyone else used medical/surgical techinques for everyday tasks? Im sure there’s more out there…(looking at you Leeuwenburg)