This case with guest Joan Davis involves a patient who experienced complications with a nasogastric tube. Joan provides valuable insights into the standards of care, potential liabilities, and the crucial role of nurses in ensuring proper insertion and monitoring. The episode takes an unexpected turn as Joan reveals the complexities of interpreting X-rays and the importance of involving a radiologist in confirming the correct placement of medical devices. This episode sheds light on an often overlooked aspect of healthcare and legal considerations and the intricate interplay of where liability of nursing and medicine intersect on inpatient cases.
This case with guest Joan Davis involves a patient who experienced complications with a nasogastric tube. Joan provides valuable insights into the standards of care, potential liabilities, and the crucial role of nurses in ensuring proper insertion and monitoring. The episode takes an unexpected turn as Joan reveals the complexities of interpreting X-rays and the importance of involving a radiologist in confirming the correct placement of medical devices. This episode sheds light on an often overlooked aspect of healthcare and legal considerations and the intricate interplay of where liability of nursing and medicine intersect on inpatient cases.
Welcome to episode 19 Of your MedMal podcast, discovering the needle nurse consultants help you discover what you didn't know that you didn't know about how to win your medical malpractice case. If you're new to our podcast, welcome, you can learn more about how behind the scenes legal nurse consulting can improve your firm's win rates and profitability. By following us on LinkedIn or visiting our website@wwwdotnplegalconsultants.com. It's time to discover the nurse consultant advantage. Let's get started. Today our guest is Joan Davis. Welcome to Med Mal Podcast
Joan:Thank you so much for having me on. It's an honor to be here.
Elisa:So Joan, tell us about your clinical background.
Joan:I've been a nurse for over 40 years initially I worked in the US I started off my career in general pediatrics and then pediatric ICU. And I was in the US for about 10 years and then I relocated back to Canada where I started working at a rural hospital. And throughout my career I gravitated towards critical care nursing. So I ended up in the emergency department in the rural hospital, and I also worked in a tertiary care hospital in the emergency department. I was asked to be a charge nurse. Which took me to all the units within the hospital. During this time, I went up north to work with the indigenous population there was no doctor on site, so all the nurses up there had to take on an advanced practice role. So that's where I learned like suturing, doing prenatal exams everything from babies all the way up to the elderly.
Elisa:What I'm hearing is you are across every spectrum there is. I heard that you've done some rural, I've heard that you've done from pediatrics to adults, to leadership roles to even doing some advanced practice services. You are familiar with standards of care in both the United States and Canada, that it's quite the breadth of a career. Yes,
Joan:I've had a great experience and I feel very fortunate to have been able to do all
Elisa:of that. Joan can be reached by emailing Joan Davis LNC at proton mail.com. That's J O A N D A V I S, LNC P R O T O N mail.com. You may also find Joan on LinkedIn by searching for Joan Davis RN legal nurse consultant. Joan, tell us about the story that you brought with you today.
Joan:So this case was basically the patient had gone from an ICU to a medical unit and the incident occurred within the medical unit. So it was good case for me because I have a kind of experienced in both areas and have worked on medical surgical units. And I have also inserted dozens of nasogastric tubes. So I have a lot of experience in that area and I could look at the documentation and pick out some of the flaws.
Elisa:These stories that occur during transition times, like shift change or transition from one unit to another or transitioning from one hospital to another, they can be a challenge. It can be a challenge to find the right consultant to look at that because consultants are gonna generally look at the, unit that they're most familiar with or that they have clinical experience on. And if they only have clinical experience in one area, they're gonna be laser focused on whether the healthcare provider or caregiver in that unit did their job properly and followed the standard of care, but they might miss standard of care violations in the transitioning or other unit.
Joan:Yeah, that's very true.
Elisa:What happened in this case?
Joan:So this is a case about a patient that had a stroke and was not able to swallow properly. So they had to insert a tube for feedings. The tube was in place for a couple of days, the patient accidentally yanked it out and it had to be replaced.
Elisa:This sounds very familiar. I feel like most nurses that have worked med-surg at all have encountered to this point a story virtually identical to what you just described. So tell our listeners a little bit more about how a stroke might lead to someone needing a nasogastric tube and what that is exactly. Maybe a little bit about some of the complications of that. Just educate those listening that may not be nurses or providers. Sure.
Joan:So with a stroke, it typically affects one side of your brain and the opposite side of your body is gonna have some degree of paralysis or difficulty maneuvering, and it affects your throat the tongue as well. So the tongue helps you push the fluid towards the back of the mouth. And if those muscles are lax, then when you go to swallow, you may choke. It's a risk of aspirating food into your lungs when you eat. So you have to have a nasogastric tube inserted.
Elisa:And nasogastric tubes are temporary solutions this situation is a hospital scenario where we've gotta get this person nutrition. They can't pass it from their mouth to their stomach on their own. So this bypasses that place where the windpipe and the esophagus kind of split off and goes right down into the esophagus so that the food can enter the stomach without a risk of entering the lungs. I think this is an interesting point too because it's really easy on cases like this to not see liability if you don't understand what the nursing standard of care is in placing and monitoring and verifying placement of an nasogastric tube.
Joan:Exactly. And that's what the lawyer said to me when I talked to him first about the case. He said, I can do the research, I can look at the literature, but I don't really understand what the nurse's position is or what she's supposed to be doing and what the responsibilities of the doctor are.
Elisa:That's so important because if you have nurse liability, then that takes that to the hospital liability. Whereas physicians are oftentimes and I don't know if this is the same in Canada and the United States, but oftentimes physicians are independent, so you have to know what entity you're suing. That's pretty critical.
Joan:Yes, exactly. Sometimes both, for sure. And in this case
Elisa:there probably was a little bit of shared liability. How was the doctor involved in this case? So
Joan:in this case, there was an x-ray done after the insertion, and the attending physician interpreted the x-ray as the nasogastric tube was down in the stomach where it should be, so the feeds could proceed. However, misinterpretation of x-rays can be pretty common after NG insertion. And if it's not being read by a qualified radiologist that can do the final interpretation, certain points might be missed. So when a nurse is going to insert an NG tube, she has to measure so that she knows the correct depth of the tube and the tube has markings all throughout the length of it. So the nurse measures from the ear lobe to the tip of the nose to the tip of the sternum or the breast bone. And that gives her measurement of how deep to insert the nasogastric tube. So that's the first step for the nurse,
Elisa:Right. If it's shallowed, we've got problems and you don't want it being too long coiling up in the stomach either the length of the tube that's critical step number one. Yeah, so that's critical,
Joan:step number one. And then the nurse proceeds to insert the tube. And while she's doing that, she really has to monitor that patient closely. So she's looking for any kind of signs of respiratory distress. Like, Are they coughing? Are they choking? Is their breathing becoming faster? Are they becoming restless and agitated you know, if you get something down your breathing tube the wrong way, it's very aggravating. The nurse really has to do an assessment as she's inserting the tube, and if she encounters any resistance, she also has to stop.
Elisa:This is going up one nostril and rounding down. Through the throat. It's horrible to think about if you've never had one placed you can imagine someone essentially forcing something down your throat can be aggravating in and of itself. Shoot, everybody will give you resistance when you're putting an NG tube down, but you're talking about physical obstruction, getting in the way, making it so that you can't advance any further.
Joan:Yes, absolutely, because you don't wanna force the tube through anything and, perforate the esophagus.
Elisa:It really is a very skilled procedure to put in an NG tube because: perforation or dislodgement into the lungs, these are really serious complications. It's definitely something you'd need a, certain level of education to do.
Joan:Yeah. And it's important if you don't have the skills to be able to recognize within yourself if you're capable of doing it, or if you need to ask somebody else that's more skilled to do the procedure for you. And if a patient has had a stroke and maybe they have an altered level of consciousness so they're not as awake or as aware as a normal person would be, then that's actually an increased risk because they're maybe not as able to communicate what they're feeling to you.
Elisa:And yeah, you might expect that person to be agitated just by nature of their condition so you might not notice some subtle changes in their agitation and things like that, that might suggest that they're physically uncomfortable. So you're measuring to make sure that it's going down deep into this esophagus and into the stomach; y ou're watching the patient as you insert this,
Joan:yeah. So when the nurse, finally gets it the measurement that she wants and she thinks it's in place, she's going to secure it. there's a special tape that goes on the nose and then it clamps around the tube so that the tube is securely into place and then whatever that measurement is as the tube exits the nose, the nurse is going to that in the nurse's note.
Elisa:One thing that, that I was taught to do was to even mark it with a Sharpie right on that spot, so that nurses coming on shift could visually see that's flush with the tip of the nose to make sure that it hasn't dislodged or slid out, I was taught to secure the end of it to the gown with tape and safety pin, because if that patient were to yank it from certain locations it could tug more on the gown than off the nose especially in confused patients. So just strategic ways that nurses devise or taught to secure it in place once it is in place.
Joan:And especially this patient had already pulled out one nasogastric tube previous to this. So once you have the tube secured you can check for placement. So there's a few different ways... Some of the traditional methods that we've used taking a syringe full of air and pushing that air through the tube into the stomach, and you listen with this stethoscope over the stomach to see if you can hear that kind of pop of air or a
Elisa:whoosh. Bubbles inside the stomach. Yeah,
Joan:Another method is taking that syringe and pulling out what you hope are stomach contents and looking at them for the color and also checking the pH with a pH paper at the bedside. Gastric contents are more acidic. So if the pH is 5.5 or less, then it's a method of confirmation that it's in the stomach.
Elisa:And then that x-ray is that ultimate determining factor? Right. And the standard of care is that's done on every patient with any kind of nasogastric or orogastric placement in the hospital setting...?
Joan:Yes. The x-ray is considered to be the gold standard. There's a strip that runs down the NG tube it's radiopaque. So the radiologist can actually follow the course of the NG tube. So there's a couple things that the radiologist has been trained to look for. He has to be able to see entire esophagus: from the top of it down to below the diaphragm, which is the muscle that divides the lungs from your abdominal cavity. And he should be able to see the nasogastric tube going down through the midline portion of the body. And the other thing, the radiologist is going to look for is the tip. And he wants to see the tip down below that diaphragm again, into the stomach. Because if it is above the diaphragm and deviating either to the right or to the left, then it's gone into the
Elisa:lung. Interesting. Yeah, it sounds like, certainly those kinds of structures are pretty subtle on that type of imaging. It's something that only a trained eye. Could see best really. You're passing through the diaphragm and your inside an esophagus, both of which are non radiopaque soft tissues, and yet it's not obviously reasonable nor efficient to get an MRI on every single patient going in for a NG tube placement to be able to see those structures exactly as they are. So really an x-ray is technologically rudimentary in terms of visualizing the actual placement, but you can infer the placement with a trained eye and a radiologist can do so much more accurately than your average provider.
Joan:Yeah, because your providers look at x-rays all the time, but to get an official report from an x-ray, you have to have it confirmed by a radiologist.
Elisa:Those are some really good insights into what that radiologist is actually looking for and-- are probably very basic for a radiologist at least. It something that just your average physician who's quote unquote familiar, if not intimately familiar with an x-ray, should be able to assess the location of the diaphragm and whether something is or is not above the diaphragm. Whether something does or does not stay midline versus deviate to one side or the other. These are very gross observations on an x-ray.
Joan:Yeah. And if the physician is just looking for that tip to say,"oh, is that tip down a certain part?" And doesn't go through all those steps and make sure it passed through this area, passed through this area, then he's, probably going to miss that it's not in the right spot.
Elisa:Yeah. Which can have evidently tragic outcomes. And then, you might have a physician come in and review a case like this and say, oh, here's your smoking gun. Yes. I am a reasonable and prudent attending general physician and I'm looking at this X-ray"and even I can see it--" of course, hindsight's 2020.--"Even I can see that this is out of place. This physician surely missed the mark here." But what that physician may not know is about the nurse's role and be able to loop that liability in.
Joan:I think a physician would've probably looked at the x-ray and judged whether the physician made the right call, if he felt that the NG looked to be in the right place or not in the right place. And I don't think a physician would have looked at the nursing notes at all to determine, what did the nurse document, what did the nurse do when she inserted the tube? Or did she just blindly insert it and send the patient off her x-ray. Because physicians don't typically insert NG tubes, they don't know all the steps that the nurse has to go through to determine what the correct placement is and how to secure it. And how they tell from shift to shift if it is indeed in the right place. And, whether they're flushing with water before they start feedings
Elisa:There's a lot that the nurses do not just once, not just at the time of placement, but routinely throughout the care of the patient to re-verify and re-verify that placement. And if there's anything awry, then they can always get another X-ray so many things, like when you walk into a room of a patient that currently has an NG tube, you're looking at the mark on that NG tube, you're looking to see that the tape is secure. You're looking again at the reaction of the patient. Are they sputtering, are they seeming to be agitated. All of this going on in our heads in an instant as we walk in the door. And then those steps that we take when we're about to change something up, give medications, we're listening for that whoosh in the stomach to see if that's still present. And, anytime we withdraw, always looking at that color. All the things that we do, and I don't even think you and I think about it in our clinical practice, you get to a point where you do all this, like riding a bike. On autopilot. And if you had to, you can sit and bullet point it out but it's just, it just goes on in your head. Is that in your experience?
Joan:Yeah, for sure.
Elisa:But, you know, I can imagine every time that goes out and comes back in, goes out and comes back in, they're having to go get an X-ray, X-ray, X-ray. But it is what it is. You gotta know every time.
Joan:Yeah. And because it's such a high risk procedure that if it's not in the right spot it's can be life-threatening. In this case the patient did end up getting tube feeding in his lung, he developed pneumonia and had to be intubated and was quite severely injured as a result of this medical error. He ended up surviving ultimately. But it was a very difficult process. and the other piece of this that I looked at when I did this case is what was the response of the nurse afterwards? She immediately took out the NG Tube, did she have a doctor come and assess the patient because he then became more distressed? Or did the rapid response team come, or, did they do some physio to the lungs to try and get rid of the extra fluid that had been put in there? So that's also, a piece that a legal nurse consultant would go on and follow through with.
Elisa:And this is where... chronology, chronology, chronology, because there are some things that just happen sometimes, but there's always that question of what was the delay in time between where we can see that evidence retroactively that it was occurring, where it should have been caught or should have been suspected to that point where it was actually diagnosed, and action taken. So what do those gaps look like? And do they fall into that reasonable and prudent timeframe?
Joan:And I always like to look at the nursing process. The systematic review that nurses go through every day, every action they take, they're using the nursing process. So they have to look at did they make a plan? Did they implement that plan? Did they evaluate after they implemented?
Elisa:And that's what they're, that's what they're trained on from nursing school. And that's specifically, is not something that a physician reviewer will be familiar with because the philosophical model that nurses function on is just different than the medical model. And especially when there's any kind of nursing involved, it really should be a legal nurse consultant.
Joan:Absolutely. I agree with you 100% there.
Elisa:Yeah. Thank you for sharing that story. I think that's a really excellent example. It's been a really interesting conversation. I appreciate you sharing with us today.
Joan:Really appreciate you having me on and I've had a great time
Elisa:You've been listening to discovering the needle nurse consultants help you discover what you didn't know that you didn't know about how to win your medical malpractice case. This podcast is a production of discovery, NP legal consultants. Discovery is the largest unified growing force of specialty nurse practitioners offering consulting services to medical malpractice attorneys who take cases for the plaintiff
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