Mu0r

So a Dobhoff has a weighted stylet at the end that helps guide the tube into the duodenum. It was marked at placement but the MD was visibly frustrated and placed it back in upon the patient pulling it out. We do indeed place NGTs but the MD has to place Dobhoffs at our facility. The patient had stated they accidentally "hit it" so restraints were not initiated. Meds were only going through the Dobhoff and not tube feedings as the patient was receiving TPN.

Hey guys, so I had a patient recently admitted to my floor. She was a 80 year old female that was hospitalized after having multiple falls at home. She fractured several of her ribs and sustained a neck injury (had a Miami-J placed afterward) secondary to her fall. They diagnosed her with compressive myelopathy and she was sent up to my unit for further care. So initially when she was admitted, she was getting her medication PO in applesauce despite being diagnosed with dysphagia which was believed to be caused by neck swelling from the neck injury. She was getting TPN as well. When I did my initial assessment, I noticed the patient had a cough and was having difficulty expectorating. Her O2 saturation was around 91-92 on room air (no significant respiratory history). I contacted the doctor immediately as I did not feel comfortable giving her PO medications. She came to the floor and placed a Dobhoff and then subsequently had a chest x-ray ordered which confirmed placement of the tube. Several hours later, the patient's husband came in and voiced his concerns about how the patient looked. She had a noticeably grayish tinge to her skin, was lethargic, and exhibiting confused behavior (which I was told was not new since her admission). The patient was receiving Dilaudid which her husband said had caused slight confusion for her during a previous hospitalization. I took a set of vital signs which were all normal except for a low-grade temperature. I truly just did not like how this patient looked and let the doctor know. At the end of the shift, I went in the room and noticed the Dobhoff had migrated out significantly due to the patient tugging at it. I let the doctor know and she came up to the unit and pushed it back in. I asked her if she wanted to do another chest x-ray and she said "No it should be fine." Now THIS is what is eating away at me. I know confirmation is imperative after placement of dobhoff of nasogastric tubes and let the oncoming staff know this. Two nights later, the patient pulled out the dobhoff completely and a nasogastric tube was placed. The nurse taking care of the patient said she was talking to her, left the room, came back in and the patient coded and was unable to be resuscitated (had pulseless electrical activity). Mind you, her vitals had all been stable but she had been newly placed on O2. I just cannot stop thinking about this situation and it truly is bothering me. Should I have done more? Did the Doctor pushing the Dobhoff back in cause a tension pneumothorax or would the code have happened sooner? I also wonder if the patient had aspirated before the Dobhoff was placed as the nurses had been giving her medications PO. Her last CBC indicated a big spike in her WBC but she did receive a 1x dose of Dexamethasone. Did she have aspiration pneumonia? The wheels in my mind keep going. Sorry for the lengthy post but I'm trying to wrap my head around exactly what happened. Opinions would be greatly appreciated!