Stoma, Voice Prosthesis troubleshooting bile expelling

[nrsgnerd]

I work as an RN in CCU/CVICU. I had a pt last night that has had a permanent stoma for years. The stoma is open with no type of appliance to hold it open. You can look straight down into it with a flashlight. At the top of the stoma, still inside the stoma, there is a small puncture hole that goes into the esophagus and the pt. had a Blom Singer voice prosthesis which is thIS little white plastic appliance that has a plastic tag that sticks out AND sits in the stoma. the very small maybe 1cm round piece fits into the hole and so he can speaK. He just occludes his stoma to do so.

Okay, so heres the problem.

1. None of us have worked with this type of stoma before, or seen this little appliance or even understand the anatomy regarding how it was installed so its hard to picture exactly what was done, we can only go on what we have been told (very little).

2. After the pt had open heart surgery, POD 1, the pt began to expel green bile from the small puncture hole

3. The pt and spouse stated that the pt. has always coughed things up into the mouth and spit them out....now, nothing makes it as far as the mouth and only expels from the hole.

Does anyone have any experience with this? The pt is still in our unit, and if there is anything I can learn to troubleshoot this prob. I would like to. I researched the net and can't find anything about bile coming out of the puncture hole. Obviously, something has happened from the time of surgery to now....for all we know anesthesia tried somehtng...who knows?

And his ENT here in GA. gave the okay to change out the appliance, allowing the pt. to do it themself. We had Resp and myself at bedside and when the pt took out the old voice prosthesis the pt began coughing and green bile, copius amounts, shot out of the small puncture and it took several minutes to get it back in. The pt. sat was already not great 90-93 (which doc gave the green light to) and then desat'd during this, we had to ambu bag the stoma....scared the hell out of me. I hope someone can shed some light fast....the worst danger in this is if it continues, bile will travel down his stoma into his lungs that already look like crap, sound like crap...its one of those shifts where you know your just not going to be able to let it go. Thanks all who read.