Something that has been eating away at me

[Mu0r]

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!

[LovingLife123]

Is a Dobhoff a feeding tube? If the patient was pulling at it, were restaurants initiated? How far did it come out? Was the cm marked at placement? That would tell you how far it came out and whether or not you needdd another KUB.

Do nurses not place feeding or NG tubes? I work on a unit where we place ourselves and can verify placement of feeding tubes ourselves. If we use an NG for feeding, we get an X-ray.

Too many questions to give an answer.

[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.

[cleback]

Did the doc replace the stylet before pushing it back in? My impression was that it is near impossible to advance after the stylet has been removed. Also its a big no-no to replace the wire when the dobhoff is in place, for reasons you already mentioned.

If the tube was in the wrong spot and you were giving meds through it, I imagine she would have gone into respiratory distress sooner, like people who aspirate... unless she was that mentally impaired. Hard to say.

I know it can be hard sometimes to advocate for the patient when you know the doc is doing something incorrectly, particularly if the doc is kind of a jerk and is obviously annoyed with the situation. I think you might talk with your manager about this. While it might reflect poorly on you that you didn't advocate for the correct policy, I think you kind of need to clear the air for your own sanity. And maybe the manager can take it back to the physician group as a reminder what correct dobhoff/ng procedures are. If your unit has a culture of being punitive, though, you may just have to swallow this as a tough lesson learned.

[AceOfHearts<3]

A chest X-ray should have shown any possible pneumonia.

I don't understand why she was getting TPN. If the issue was swallowing a NG tube should have been placed initially and the patient started on enteral feeding. TPN should only be used when enteral feeding is not an option as TPN requires a central line and carries significant infection risks. The sugar and everything in TPN make it a favorable place for bacteria/fungus, plus add in the central line and it's the perfect recipe for sepsis from bacteremia.

Fractured ribs are painful and can make taking deep breaths difficult, which could explain her low O2 sats. They could also cause a pneumo, but that should all show up on a chest X-ray.

She coded 2 days after you had her and after a new NGT was placed. She should have had another chest X-ray at that point. My thinking is that her death was not caused by anything that happened while you cared for her. It's impossible to say for certain or to know what happened with the info provided, but it certainly sounds like she was a very sick lady. I'm wondering if the cause of her falls was investigated-sometimes it's as simple as just losing balance, but it could have been caused by something medical. Did she have a cardiac workup done when admitted? Maybe something was going on which made her dizzy or have syncopal episodes that nobody witnessed and it was just assumed were regular falls.

[AceOfHearts<3]

Did the doc replace the stylet before pushing it back in? My impression was that it is near impossible to advance after the stylet has been removed. Also its a big no-no to replace the wire when the dobhoff is in place, for reasons you already mentioned.

I've had a patient pull out their dobhoff tube all the way before and we've reinserted the same one with no guidewire with no issues. We got it back in very easily the first try and a chest X-ray confirmed the placement.

[JKL33]

There are more likely things than a tension pneumo from the dubhoff or the NGT, although here's a case of exactly what you're talking about. Maybe she threw a PE, which, when it is the direct cause of cardiac arrest, often presents with an arrest rhythm of PEA. It's impossible to say what happened without an autopsy, and in these situations I think we should be very cautious in how we discuss it IRL.

[Been there,done that, ASN, RN]

I think your actions were prudent. My assessment would be she developed aspiration pneumonia on day one. It takes awhile to show on x-ray.

It's good to try to learn from a death, but please don't obsess over it.

[NursesRmofun, ASN, RN]

You'll never know for sure. Don't beat yourself up too much.

[RNperdiem, RN]

I take care of elderly patients with rib fractures a lot. They can have a high rate of respiratory failure.

You say that the feeding tube issue took place two days before she coded and died. I would expect a patient like her to be getting daily X-rays. If the tube was out of place, and caused a tension pneumo, I doubt it would go unnoticed for two days.

Are you in the ICU? When I worked the floor with unmonitored patients, subtle changes in vital signs are not apparent and often it is late in the game before we call a rapid response.

[LibraNurse27, BSN, RN]

I have usually seen new CXRs ordered after a tube comes out and is re-inserted but not always and not sure if that is the standard of practice across the board; curious to hear from others with more experience on this. Regardless, I think if the tube had been accidentally inserted into the patient's lung or trachea she would have developed respiratory distress right away. It sounds like she had a lot of comorbidities that combined could have led to her death. I think the biggest lesson to be learned is to feel more comfortable advocating when you feel something is important even if it means annoying a doctor. But I doubt the repeat CXR would have saved this patient's life and I hope you can realize that so many factors were involved in this woman's care as well as her death and forgive yourself for whatever role you feel you have in this, learn from the experience and continue to practice good nursing care =)

[Glycerine82, LPN]

You did the best you could do in the situation you were in. If she was aspirations on applesauce speech needed to eval her and place her on NPO status far before you got to her. Not your fault, at all. Good learning experience, though.