Consulting other services for "basic" skills

[Stagg737]

Wow. This is very different from my training experience. I felt that my medical school was very good as far as requiring medical students to be involved, but I don't think I had any sort of requirement to even place IVs or Foleys. I definitely never tried an NG tube. They had a basic lab where we put one in on a mannequin, but that's it.

That's really interesting. And you know, I really don't even know how to troubleshoot an NG tube. I've had my attendings come in and start messing with them to fix whatever is wrong, and I don't know the least bit about it. This is making me realize I really know nothing about an NG tube except when the patient needs one and when it's ok to remove one. Definitely a big lack of knowledge there.

Just a lowly M4, but I think this shows some of the massive differences in clinical education from med school to med school, and other posts have pointed out differences in residency. Where I rotated, I was expected to place foley's, IVs, nasal trumpets, and several other 'basic' procedures. Got to place a few NG tubes as well as several other non-required techniques. On a later rotation (different institution) I encountered interns who had never placed a foley or really done anything because it was a "nursing job" and I actually ended up teaching them some of the more basic things (including DREs...). I always just assumed that physicians need to be proficient at pretty much everything related to their field, as we're ultimately the ones that the liability will fall to. This has been an interesting thread, thanks to all!

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[Wordead]

I was wondering if these expectations that urology place their own NG tubes holds at the attending level. I guess it's one thing to expect residents to do something at an academic hospital, but what about a private practice urologist?

Well in private practice it's a lot less aggravating to get these idiotic consults since you get paid for 5 minutes of work. I'd still find it sad that an attending surgeon couldn't put in a NG.

I don't accept that once you haven't done it for long enough it's a good excuse to just consult everyone else. I think that's a failure on your part to keep up your skills. Can I say as an attending I haven't had to work up chest pain or fevers in a long time so I'm just going to get someone else to do everything? Sure, the answer is yes. But I'd consider that a failure as a doctor.

 

[DoctwoB]

I was wondering if these expectations that urology place their own NG tubes holds at the attending level. I guess it's one thing to expect residents to do something at an academic hospital, but what about a private practice urologist?

We run into some issues regarding central lines, where I don’t believe our Uro attending are credentialed for them. I put in plenty on gensurg and ICU and feel comfortable with every approach except US guided subclavian, but our attendings can’t technically supervise them so unless a patient is tanking and we just do it anyways we occasionally have to consult or use more PICCs then we probably should.

 

[filter07]

I think SLUser's post was closest to how I feel about this topic. Although most internships should cover NGT, the OP said 6 months of internship was urology and other months SICU. It's conceivable that no NGT was needed to be done. Although a small part that might be a personal issue, I think it's more reflective of the specific training program as a whole, and to some extent training programs throughout the country these days. People are learning fewer hands on procedures everywhere and expertise is gained much later in training. That's a problem that's not going away...

When I was an intern 10 years ago, I had a few people get ileus and need NGT on the floor. Of course the nurse tried and couldn't get it. So they call me, the intern, who has done at most a few of these. But I know the anatomy and can reason through some troubleshooting. So I go there, try, the patient gags, gives me the death stare and then refuses. At that point you have a few options. One is to go to your computer and document that the patient refuses and then wait for them to aspirate. Another is to try again using a different technique or adjunct and trying to get the patient to understand that they need this done. Third is to get help.

In my training program, getting help is not an option. Well, it is, but really it isn't. The amount of s*** you would get for calling your senior resident to help you with this is just a world of hurt you want to avoid if at all possible. Old school program. And waiting for them to aspirate and then telling your attendings that it's cool your patient died because they signed a waiver wasn't a really good option either.

There was a pervasive and extremely important mentality I had during all the years of training: there is no one else. You're it. You're the last line of defense. Nurses don't function with this mentality. As a general surgeon this was pervasive.

Now granted when that GSW wound comes in with a bullet in the aorta, you don't REALLY think you're the last line of defense, but that's the default mentality for most of the things I encounter in residency. NGT, aline, central line... As an attending, when I got called in at night to place a central line on a tiny guy with contractures everywhere and a history of central lines for 40 years, and the guy is septic and needs a line, I just approach it like I approach most things: If I can't get this done, there is no one else to call. The patient just doesn't get the line. Period.

Now have I ever called Urology for a foley? Sure, but after the nurse failed, I tried a bigger catheter, a coude, etc. You have to function like there's no calvary - even if you eventually need to get bailed out by them from time to time. And if you approach patient care with this during your training, you won't be a chief resident or attending that has a huge list of things you're "not comfortable with".

 

[DoctwoB]

I agree with the basic premise of taking responsibility for getting the job done and focusing on the outcome rather then the process of “trying”, and agree that refusing to fail can make more difference then pure skill. For example, I’ve placed many peripherals that IV team couldn’t, despite the fact that I do them rarely and they have vastly more experience, likely just because I was willing to keep trying.

The key of course is knowing when your persistence is harming the patient compared to a person better suited for the job. Some have talked about how when they call Urology it’s only because the patient had to be scoped to get a catheter. Well I can guarantee you that if you jab a prostate enough times and create a mess of false passages that you just bought that patient a scope and foley for a week (with risk of UTI and future stricture from trauma) or Suprapubic tube when maybe an 18 coude with better technique would have solved the job off the bat. There needs to be a balance of training to handle things oneself and patient considerations/safety and one can take personal ownership of a patient and their problems while acknowledging your own limitations.

 

[startswithb]

At my large academic institution general surgery may have even been consulted for "ileus" and then would have been called with issues with NGT placement without much grief. We have a very good relationship with our general surgery colleagues as many of our attendings operate as co-surgeons and consult on our respective issues frequently. In this instance above, I would have attempted if the GS resident was not immediately available and if they were I would be at bedside for assistance. If this was a case where the urology resident was on home call and called GS for a consult without seeing the patient I would find that unacceptable. General surgery is also the only surgical specialty that will attempt foley catheters which is something we appreciate. I have had neurosurgeons blatantly refuse to attempt even if the person had no risk factors for a difficult foley and post-operative retention is extremely common in neurosurgical patients.

 

[cpants]

I was wondering if these expectations that urology place their own NG tubes holds at the attending level. I guess it's one thing to expect residents to do something at an academic hospital, but what about a private practice urologist?

Good question, and you're very right that the private practice world is a lot different. At my private community hospital, nurses do not place NG tubes. So what would happen if my postop nephrectomy with ileus needs one? Well, if I was at the bedside I would put it in myself. If I was at home in bed at 2 in the morning (assuming the patient is stable), I would probably call the in-house general surgery PA to see the patient and put the tube in. My GS colleague gets an easy ileus consult (ie. free money)...one hand washes the other...everyone wins.

At an academic institution, the residents are trying to turf work onto the other services. They are overworked and underpaid with strong incentive to avoid additional scutwork. But these residency battles about not doing consults and throwing shade on the consulting doctors largely don't exist in the real world. In general, subspecialists, hospitalists, even the ER docs have very collegial relationships with each other, and the response to any request is pretty much "no problem". All those stupid urinary retention consults I hated in residency take me five minutes and put a few bucks in my pocket. In return, the hospitalist is happy to manage the complex medical issues of my postop TURP, which I'm sure is not overly stimulating for them. They admit every kidney stone that comes in without question.

Insist that a surgeon or hospitalist tries a foley before I come in? Yea right...you suck it up and do it. If it's easy....that's better! If you think they are stupid, you keep it to yourself.

I will tell you that pretty much any attending urologist you ask will think you should be able to put in an NG tube. It's an older field and most in practice did 2 full years of general surgery. Whether they actually still do the insertions when necessary probably varies.

 

[armybound]

It's amazing to me how different everyone's experience is than my own. I talked to my father in law about it (a colorectal surgeon at my institution) who said we're spoiled by nurses who are tasked with NG tubes and Foleys. Seeing anyone other than urology say they have tried catheters before calling urology is a completely foreign concept to me. That just doesn't happen where I am.

But you all have motivated me to try to get my team to become at least basically proficient in NG tube placement. I know I personally will try instead of asking a nurse to do it, and if I have to call someone for help, I will personally be present.

I really appreciate the input. This thread turned out way more interesting to me than I imagined it would be.

 

[operaman]

Interesting thread and an important topic that doesn’t get thoughtfully discussed very often, especially by the caliber of people who’ve posted here.

In ENT, 2 years ago we changed our intern year to require 6 months of ENT and some other assorted requirements. I wonder if we will run into similar things as time goes on. Mine was the last traditional internship year and I got to do quite a few of these routine bedside procedures. My Med school was also one that required us to log a certain number of NGs and Foleys whatnot on our surgery rotation. It will be interesting to see how this plays out over the long term.

We occasionally get consulted for NG placement - seems to come in waves once we’ve done a couple and other services get the idea that that’s what we do. As noted earlier, some of these are people with skull base issues or upper airway injury or masses where the tube needs to be done under direct visualization. Others are the “we’ve tried and can’t get it” variety. I don’t usually give much pushback on these because I feel bad for the poor patient who has had a tube rammed repeatedly into his middle turbinate, but if I can safely place it without a scope on my first try then it’s probably not something that needs ent consultation. We don’t place many NGs in our field, but obviously we do a lot of other procedures in the area where the basic skills carry over. I do usually ask that the primary team have residents there so we can troubleshoot what went wrong.

Some tricks I’ve used to make it easier:
1) do a basic exam of the nose and pharynx. If one side of the nose looks jacked, try putting the tube on the other side. Try to notice the big pharyngeal mass before ramming a tube into it.
2) numb and decongest the nose. I carry a spray bottle of a tetracaine/afrin combo to use for adult endoscopy and it makes the NG experience much better. pharmacy will also make this when asked.
3) if not contraindicated, I’ll frequently numb the pharynx with a small spray of cetacaine as well. I find this especially helpful for gagging patients. If I ever need one, I’m spraying this on myself.
4) put some lube on the tube
5) stay on the floor of the nose. This ends up feeling like you’re aiming slightly inferiorly. All the “we can’t get it” consults have failed at this step. It doesn’t take much angling superiorly before you’re ramming into the middle turb.
6) put the biggest tube in that you can. I find them easier to place and they are less likely to get clogged. The only thing that sucks more than getting an NG tube is getting 2 NG tubes.
7) secure the tube. I personally like those little magnetic bridles that loop a tie around the septum.

 

[vhawk]

Good question, and you're very right that the private practice world is a lot different. At my private community hospital, nurses do not place NG tubes. So what would happen if my postop nephrectomy with ileus needs one? Well, if I was at the bedside I would put it in myself. If I was at home in bed at 2 in the morning (assuming the patient is stable), I would probably call the in-house general surgery PA to see the patient and put the tube in. My GS colleague gets an easy ileus consult (ie. free money)...one hand washes the other...everyone wins.

At an academic institution, the residents are trying to turf work onto the other services. They are overworked and underpaid with strong incentive to avoid additional scutwork. But these residency battles about not doing consults and throwing shade on the consulting doctors largely don't exist in the real world. In general, subspecialists, hospitalists, even the ER docs have very collegial relationships with each other, and the response to any request is pretty much "no problem". All those stupid urinary retention consults I hated in residency take me five minutes and put a few bucks in my pocket. In return, the hospitalist is happy to manage the complex medical issues of my postop TURP, which I'm sure is not overly stimulating for them. They admit every kidney stone that comes in without question.

Insist that a surgeon or hospitalist tries a foley before I come in? Yea right...you suck it up and do it. If it's easy....that's better! If you think they are stupid, you keep it to yourself.

I will tell you that pretty much any attending urologist you ask will think you should be able to put in an NG tube. It's an older field and most in practice did 2 full years of general surgery. Whether they actually still do the insertions when necessary probably varies.

I've always had more respect and appreciation for this "private practice" mode of thinking, but then again in my residency we rotated with a private group for probably about 25% of our time overall and it was sort of ingrained into me.

 

[armybound]

Interesting thread and an important topic that doesn’t get thoughtfully discussed very often, especially by the caliber of people who’ve posted here.

In ENT, 2 years ago we changed our intern year to require 6 months of ENT and some other assorted requirements. I wonder if we will run into similar things as time goes on. Mine was the last traditional internship year and I got to do quite a few of these routine bedside procedures. My Med school was also one that required us to log a certain number of NGs and Foleys whatnot on our surgery rotation. It will be interesting to see how this plays out over the long term.

We occasionally get consulted for NG placement - seems to come in waves once we’ve done a couple and other services get the idea that that’s what we do. As noted earlier, some of these are people with skull base issues or upper airway injury or masses where the tube needs to be done under direct visualization. Others are the “we’ve tried and can’t get it” variety. I don’t usually give much pushback on these because I feel bad for the poor patient who has had a tube rammed repeatedly into his middle turbinate, but if I can safely place it without a scope on my first try then it’s probably not something that needs ent consultation. We don’t place many NGs in our field, but obviously we do a lot of other procedures in the area where the basic skills carry over. I do usually ask that the primary team have residents there so we can troubleshoot what went wrong.

Some tricks I’ve used to make it easier:
1) do a basic exam of the nose and pharynx. If one side of the nose looks jacked, try putting the tube on the other side. Try to notice the big pharyngeal mass before ramming a tube into it.
2) numb and decongest the nose. I carry a spray bottle of a tetracaine/afrin combo to use for adult endoscopy and it makes the NG experience much better. pharmacy will also make this when asked.
3) if not contraindicated, I’ll frequently numb the pharynx with a small spray of cetacaine as well. I find this especially helpful for gagging patients. If I ever need one, I’m spraying this on myself.
4) put some lube on the tube
5) stay on the floor of the nose. This ends up feeling like you’re aiming slightly inferiorly. All the “we can’t get it” consults have failed at this step. It doesn’t take much angling superiorly before you’re ramming into the middle turb.
6) put the biggest tube in that you can. I find them easier to place and they are less likely to get clogged. The only thing that sucks more than getting an NG tube is getting 2 NG tubes.
7) secure the tube. I personally like those little magnetic bridles that loop a tie around the septum.

Great response, thank you.

How does ENT do this under direct visualization? Do you use a wire of some sort through your scope?

 

[armybound]

I've always had more respect and appreciation for this "private practice" mode of thinking, but then again in my residency we rotated with a private group for probably about 25% of our time overall and it was sort of ingrained into me.

We have a separate part of our residency that's private practice, and they definitely let us know that we should appreciate the stupid post-op urinary retention and "difficult" Foleys that aren't difficult because that's easy money. Our residency program has changed in the past few years though, and the younger residents no longer get this private practice experience, so their attitude toward those sorts of things is different than mine. If I get called for a difficult Foley, I run off and do it. If they get called, they argue with the consultant, argue with the nurses, and basically delay the inevitable because they're annoyed by it.

At the main institution I'm mainly discussing here, it's a big multispecialty group practice and there's none of that. Basically residents running everything, trying to avoid work, arguing with other services about their stupid consults, etc. It's not at all the way that I see the private hospital run.

 

[operaman]

Great response, thank you.

How does ENT do this under direct visualization? Do you use a wire of some sort through your scope?

Nothing so refined I'm afraid. For us it's not so much trying to thread the tube through a stricture as it is just ensuring that it passes safely without going into a known pharyngeal defect, going into a recently reconstructed airway, avoiding large friable tumors, not coiling and going up into the brain through a skull base fracture, etc. We have nice distal chip scopes with working channels in our clinics so we could theoretically pass a wire first and then seldinger the tube over it, but I haven't seen us do that yet.

Usually I'll perform a fiberoptic endoscopy first to visualize the relevant anatomy. If there's an anterior skull base issue, I'll run the scope parallel to the tube in the nose until I get to the nasopharynx. Then I'll withdraw the scope and place it in the other naris and advance til I can see the tip of the tube. Then it's just a matter of slowly advancing the tube and watching to make sure it goes into the esophagus without getting into trouble on the way.

 

[mimelim]

Most of the important things have been covered pretty well so let me just comment on one thing. You said a few times "I figured if an experienced nurse couldn't get it, then I was unlikely to be successful." The following things about that statement are all, simultaneously, true:

1) your assessment of the situation is actually probably accurate
2) your assessment is very often used as a rationalization for being lazy
3) your assessment is something that every single one of us has said at some point during training, and most of us got away with it, most of the time
4) your assessment is completely indefensible in any sort of hindsight situation, be that legal proceeding, m&m, answering to your attending, etc

I disagree with this from watching a recent trial locally and discussion with an ADA (*cough* my wife *cough*). From a strictly legal perspective, if you have performed a procedure that is not in your discipline 0-1 times you are in a far better position if you decline to do so to defer to someone else if others that are more experienced have failed. This isn't a "I wasn't likely to be successful", this is a, "I didn't want to subject the patient to a procedure that I don't perform on a regular basis and clearly don't feel comfortable performing." The vast majority of your assessments boil down to a systemic issue with surgical training and the "king of the hill" mantra that is espoused by surgeons everywhere and isn't really based on sound legal principle or any real guiding ethics for that matter.

I know that I am late to the party, but it would take pretty exceptional circumstances for me to place an NG tube. While I'm sure some of my faculty would chastise me with the standard, "In my days as a resident... etc" I would feel incredibly comfortable firing right back with the best interests of the patient in an M&M setting. Obviously every department is different, but from a neutral third party observer perspective, it is illogical to come to any other reasonable conclusion. I certainly agree with the whole taking ownership of your education, getting comfortable with other aspects of care that aren't your own, but are closely related, etc. I think my posting history demonstrates that I am solidly on the 'going overboard' side of things. But, there are limits. If you don't see NG tube placement as a part of your training because the number of patients requiring it is that low, you shouldn't be placing them.

Honestly, after 6 years of training, I think that physician, and specifically surgeon, hubris and "I need to handle everything" is far more dangerous than humility in knowing when you are out of your depth and need someone else to do something. So much so that after those 6 years, if I wanted to really make money, I would just leave medicine and setup a medical malpractice firm that only focuses on it. Easy money.

 

[vhawk]

I'm not a lawyer, you might be right. But "Well, we've got 3 experienced urologists who all say it is a standard skill that every surgeon should be capable of performing" and "So rather than attempt a skill that you are supposed to know, you consulted another service and in the time it took them to respond this patient died" seem like they would be compelling arguments to a jury to me. Coupled with "despite only having performed this procedure a few times, I felt that the patient was at risk of serious complication if it wasnt attempted and so I did the best I could."

I've always been told that sins of commission are much easier to defend than sins of omission. But I could be very wrong, certainly.

I mean....where does this line of reasoning end? For almost anything that happens in the hospital, there is probably someone on call who is better at it than I am, with a few pretty narrow exceptions. My patient is complaining of chest pain. Sure, I COULD go asess the patient, order some tests, and work it up...but I mean, I'm not a cardiologist. Is it in the patients best interest for me to handle it, or for the expert? My patients potassium is 5.4. Sure, I know some basic steps to try to treat this, but I'm not a nephrologist. Most of the time I'll manage but once in a while I'm gonna screw it up. Should I consult renal?

I get that surgeon hubris is a problem, but what you are advocating appears, at least to me, to incentivize ignorance. You are way better off if you just dont know how to do ANYTHING, right?

 

[mimelim]

I'm not a lawyer, you might be right. But "Well, we've got 3 experienced urologists who all say it is a standard skill that every surgeon should be capable of performing" and "So rather than attempt a skill that you are supposed to know, you consulted another service and in the time it took them to respond this patient died" seem like they would be compelling arguments to a jury to me. Coupled with "despite only having performed this procedure a few times, I felt that the patient was at risk of serious complication if it wasnt attempted and so I did the best I could."

I've always been told that sins of commission are much easier to defend than sins of omission. But I could be very wrong, certainly.

I mean....where does this line of reasoning end? For almost anything that happens in the hospital, there is probably someone on call who is better at it than I am, with a few pretty narrow exceptions. My patient is complaining of chest pain. Sure, I COULD go asess the patient, order some tests, and work it up...but I mean, I'm not a cardiologist. Is it in the patients best interest for me to handle it, or for the expert? My patients potassium is 5.4. Sure, I know some basic steps to try to treat this, but I'm not a nephrologist. Most of the time I'll manage but once in a while I'm gonna screw it up. Should I consult renal?

I get that surgeon hubris is a problem, but what you are advocating appears, at least to me, to incentivize ignorance. You are way better off if you just dont know how to do ANYTHING, right?

I disagree on the legal aspect. No way to prove either way without an actual case going through the courts, but attempting a skill that you "are supposed to know", but don't (something surgeons/residents do fairly often) is asking for far more trouble. This is especially true if you KNOW you don't know, which is incredibly easy to prove with case logs. Ultimately as the resident, this would fall on the faculty who was supervising (or more likely, not supervising). The resident can certainly be faulted for not bumping things up the chain for sure, but if they weren't trained to do something, it is on the faculty and the residency, at least from the legal perspective. Obviously, they will get **** on left and right by people, but personally, in this case? I think that that is wrong. NG tubes are not a part of my training. While some of our patients certainly have them, it is incredibly rare for me to be managing it, much less placing/removing etc. I suspect that as medicine further sub-specializes and we limit the amount of general surgery exposure this will not be uncommon.

As for how far? I think the honest and best answer is, as far as YOU the provider wants and feels comfortable. It is an unsatisfactory answer for many/most because it doesn't fit inside their neat little boxes, but frankly I don't see any other way of doing it. If a patient is presenting with something that you have not been trained to deal with, you should not be dealing with it. By the same token, you shouldn't be compensated for taking care of those issues either. I know basic chest pain workup and a fair amount of nephrology because that is what I see and do every day. But, I don't expect a radiologist doing a procedure to do a chest pain workup when they don't train to deal with it and don't see it semi-regularly. I expect them to see the patient, assess that it is beyond their training to care for them and get assistance efficiently. I will manage my patient's hyperkalemia because in my training I do it at least 5-6 times a week. But, I will defer to nephrology in almost all non-ESRD patients after the most basic steps are taken because it is in the best interest of the patient that I am not the primary person watching the labs and caring for it. There is a limit/boundary that I have identified and feel very comfortable with from a personal, ethical and legal stand point. If there ISN'T another provider readily available and I can honestly say to a court and more importantly, to myself that it was in the best interest of the patient that I do something beyond what I feel completely comfortable with, then I will do it. For example, I had a belly pain + BRBPR several hours after one of my EVARs, GI said they would scope in the morning despite my arguing and my two CRS were operating in another hospital. So I scoped the patient myself. As a vascular resident, that is a skill set that is beyond what we are expected to have, but clearly useful. (Now of course I have 80+ documented colonoscopies from my PGY1/2 years, but that is a seperate issue, so I feel rather protected).

As with everything, it is a balancing act. If you don't know anything and nobody can refer things to you, then you won't stay in business. If you get known as completely useless except for a very narrow focused area, you aren't going to be very desirable to most referring doctors. In the last year, I have gone out of my way to learn procedures that are primarily performed by cardiologists, cardiac surgeons, spine surgeons and plastic surgeons, because I want to be comfortable with many things that are desirable in a recent vascular surgery graduate that can 'fill in the cracks' wherever I end up. But, while I have a working knowledge of foleys and NG tubes, they are not so emergent that better help can be found than I. I strongly dislike the concept of, "I must be able to handle EVERYTHING." as I mentioned before. But then again, I'm on the 'odder' side of things when it comes to roles in healthcare as I am a rather staunch supporter of most of what physicians do being done by non-physicians (see the numerous threads about NP/PAs) etc. *shrug*

 

[doc05]

I disagree on the legal aspect. No way to prove either way without an actual case going through the courts, but attempting a skill that you "are supposed to know", but don't (something surgeons/residents do fairly often) is asking for far more trouble. This is especially true if you KNOW you don't know, which is incredibly easy to prove with case logs. Ultimately as the resident, this would fall on the faculty who was supervising (or more likely, not supervising). The resident can certainly be faulted for not bumping things up the chain for sure, but if they weren't trained to do something, it is on the faculty and the residency, at least from the legal perspective. Obviously, they will get **** on left and right by people, but personally, in this case? I think that that is wrong. NG tubes are not a part of my training. While some of our patients certainly have them, it is incredibly rare for me to be managing it, much less placing/removing etc. I suspect that as medicine further sub-specializes and we limit the amount of general surgery exposure this will not be uncommon.

As for how far? I think the honest and best answer is, as far as YOU the provider wants and feels comfortable. It is an unsatisfactory answer for many/most because it doesn't fit inside their neat little boxes, but frankly I don't see any other way of doing it. If a patient is presenting with something that you have not been trained to deal with, you should not be dealing with it. By the same token, you shouldn't be compensated for taking care of those issues either. I know basic chest pain workup and a fair amount of nephrology because that is what I see and do every day. But, I don't expect a radiologist doing a procedure to do a chest pain workup when they don't train to deal with it and don't see it semi-regularly. I expect them to see the patient, assess that it is beyond their training to care for them and get assistance efficiently. I will manage my patient's hyperkalemia because in my training I do it at least 5-6 times a week. But, I will defer to nephrology in almost all non-ESRD patients after the most basic steps are taken because it is in the best interest of the patient that I am not the primary person watching the labs and caring for it. There is a limit/boundary that I have identified and feel very comfortable with from a personal, ethical and legal stand point. If there ISN'T another provider readily available and I can honestly say to a court and more importantly, to myself that it was in the best interest of the patient that I do something beyond what I feel completely comfortable with, then I will do it. For example, I had a belly pain + BRBPR several hours after one of my EVARs, GI said they would scope in the morning despite my arguing and my two CRS were operating in another hospital. So I scoped the patient myself. As a vascular resident, that is a skill set that is beyond what we are expected to have, but clearly useful. (Now of course I have 80+ documented colonoscopies from my PGY1/2 years, but that is a seperate issue, so I feel rather protected).

As with everything, it is a balancing act. If you don't know anything and nobody can refer things to you, then you won't stay in business. If you get known as completely useless except for a very narrow focused area, you aren't going to be very desirable to most referring doctors. In the last year, I have gone out of my way to learn procedures that are primarily performed by cardiologists, cardiac surgeons, spine surgeons and plastic surgeons, because I want to be comfortable with many things that are desirable in a recent vascular surgery graduate that can 'fill in the cracks' wherever I end up. But, while I have a working knowledge of foleys and NG tubes, they are not so emergent that better help can be found than I. I strongly dislike the concept of, "I must be able to handle EVERYTHING." as I mentioned before. But then again, I'm on the 'odder' side of things when it comes to roles in healthcare as I am a rather staunch supporter of most of what physicians do being done by non-physicians (see the numerous threads about NP/PAs) etc. *shrug*

"NG tubes are not a part of my training"?? I thought you're at an ivory tower vascular program. Do your open aortas never get ileus? Of course they do. Suggesting that it's not a part of your training is ridiculous. And I cannot imagine any expert witness who would suggest it's beyond your skill set.

 

[mimelim]

"NG tubes are not a part of my training"?? I thought you're at an ivory tower vascular program. Do your open aortas never get ileus? Of course they do. Suggesting that it's not a part of your training is ridiculous. And I cannot imagine any expert witness who would suggest it's beyond your skill set.

What I think is ridiculous is that you think that if something is connected to an operation or it's complications that it MUST be a part of your armament based purely on that association. I find this to be incredibly inconsistent at best and completely illogical at worst. Training paradigms change. Practice patterns change. To be honest, it is a bit telling that someone would bring up open aortas. I'm in a high volume program, I will do about 25 open aortas before graduating. That is about as high as anyone in the US. The vast majority will do 5-10 (and I'm skeptical that some programs even get their trainees 5). The "abdominal" ACGME requirement is satisfied by a heck of a lot more than open aortas and does not require violation of the peritoneum. Do you know what fraction of our total cases those make up? I am in no way saying that it isn't a good skill set to know or have in your back pocket. But, to suggest that having never been taught something and having never doing something is a "part of your training" is laughable. There are plenty of trainees who will never place an NG tube when they graduate residency. We can argue whether or not that is a good idea or not, but that is a fact. To suggest that someone who made the conscious decision get help when they weren't comfortable or trying to make them feel bad about it is asinine and dangerous practice (while completely consistent with how much of medicine is practiced.)

To go completely egotistical... There is nothing that is beyond my skill set. I am a highly motivated and well trained PGY6, if I spend the time to learn it, I may not be the best in the world at it, but it is hard to imagine something that I won't be at least competent in. But, that does not mean that I am responsible for learning or liable for all things that I COULD learn to do. That standard would be ridiculous. That standard is certainly not seen outside of medicine and is certainly not seen in non-surgical specialties.

 

[Wordead]

What I think is ridiculous is that you think that if something is connected to an operation or it's complications that it MUST be a part of your armament based purely on that association. I find this to be incredibly inconsistent at best and completely illogical at worst. Training paradigms change. Practice patterns change. To be honest, it is a bit telling that someone would bring up open aortas. I'm in a high volume program, I will do about 25 open aortas before graduating. That is about as high as anyone in the US. The vast majority will do 5-10 (and I'm skeptical that some programs even get their trainees 5). The "abdominal" ACGME requirement is satisfied by a heck of a lot more than open aortas and does not require violation of the peritoneum. Do you know what fraction of our total cases those make up? I am in no way saying that it isn't a good skill set to know or have in your back pocket. But, to suggest that having never been taught something and having never doing something is a "part of your training" is laughable. There are plenty of trainees who will never place an NG tube when they graduate residency. We can argue whether or not that is a good idea or not, but that is a fact. To suggest that someone who made the conscious decision get help when they weren't comfortable or trying to make them feel bad about it is asinine and dangerous practice (while completely consistent with how much of medicine is practiced.)

To go completely egotistical... There is nothing that is beyond my skill set. I am a highly motivated and well trained PGY6, if I spend the time to learn it, I may not be the best in the world at it, but it is hard to imagine something that I won't be at least competent in. But, that does not mean that I am responsible for learning or liable for all things that I COULD learn to do. That standard would be ridiculous. That standard is certainly not seen outside of medicine and is certainly not seen in non-surgical specialties.

I get that patterns are different at other institutions and training is variable. It's mind-blowing to me that a vascular surgeon wouldn't feel comfortable placing a NG though. Our integrated vascular residents have 2-3 years of GS infolded - is that variable? From what you're describing it sounds like your program doesn't do much general surgery?

 

[mimelim]

I get that patterns are different at other institutions and training is variable. It's mind-blowing to me that a vascular surgeon wouldn't feel comfortable placing a NG though. Our integrated vascular residents have 2-3 years of GS infolded - is that variable? From what you're describing it sounds like your program doesn't do much general surgery?

The requirement is 24 months of "core" surgery. How you divide that up is quite variable. There is active discussion of dropping that to 18 or possible 12 months.

It has been 4 years since I placed an NG tube and I certainly didn't do many back when I originally did them. If a patient needs an NG tube, I can try to place one. But, when an experienced ICU nurse and her charge tell me that they couldn't get it, I'm not going to come into the hospital to do it. Obviously, it depends on how well you know your nursing staff and their capabilities. But, this concept of, well, you are a physician, so you must try, even if others have failed is inefficient and illogical.

 

[VisionaryTics]

Although I'm amused by my occasional consult for NGT placement, I quickly decided in residency never to get frustrated or push back on "basic" consults.

People calling in consults want help. There's a lot of macho chest puffing in academic residency (especially amongst surgeons), but I think it's completely reasonable for a physician to place a consult for a procedure they're not comfortable with if they think it's in the patient's best interest.

I'm not arguing that every problem outside your field needs a consult, but every physician has a different threshold on what they feel they can do safely for a patient. And as a consultant, I can't tell what that threshold is for other physicians. So I say "thanks, I'll see them soon".

 

[armybound]

WELL I WOULDN'T TAKE CARE OF YOU ANYWAY, EVEN IF YOU BEGGED ME TO

 

[Psai]

A lot of holier than thou bags in here

 

[rongeur]

The requirement is 24 months of "core" surgery. How you divide that up is quite variable. There is active discussion of dropping that to 18 or possible 12 months.

It has been 4 years since I placed an NG tube and I certainly didn't do many back when I originally did them. If a patient needs an NG tube, I can try to place one. But, when an experienced ICU nurse and her charge tell me that they couldn't get it, I'm not going to come into the hospital to do it. Obviously, it depends on how well you know your nursing staff and their capabilities. But, this concept of, well, you are a physician, so you must try, even if others have failed is inefficient and illogical.

I just have to chime in and say: it's really not. Overall as a resident I think my success rate on "nursing failed and said it's impossible" tasks that they did 100x more often than me was at least 85%+, ranging from PIVs to NGTs to foleys. And it's not cause I'm great, it's just being a surgeon. Most of it boils down to the mentality. Nurses do not get much experience with invasive procedures and are usually more afraid of causing harm than failing. They're not going to get in any trouble if they say "couldn't do it" but they will get (they imagine) in lots of trouble if they cause a problem, even leading to the eternally-cited "Risking My License" sequelae. They're also (for better or worse) much less comfortable causing patients temporary discomfort.

I don't have a huge opinion on this specific discussion except to say that NGTs really are a unique category. Even Foleys one can argue for getting a specialist in when you fail due to complications from too many repeat failures. This is like literally THE ONLY procedure medical students are allowed to basically do unsupervised in many places. Think about that for a second. If I did abdominal surgery I would personally be too embarrassed to call a consult for NGT without having at least tried for fear they might send over the MS3 to do it...

 

[DoctwoB]

Wow... After reading the whole thread I must say it's genuinely scary that so many residents/fellows/attendings in the US are engaging in this level of mental gymnastics to justify their laziness/deficiencies to learn a "procedure" that can be mastered by an MS3 in about an hour.

I can't see a reason why even a Psychiatrist or Dermatologist wouldn't try to put an NGT if their patients needed one. Let alone other "surgical" specialties.

"Nurses can't, so of course I can't either"? Geez.

Grow up and pick one single day of your life to put an NGT on some patients. If you're in a hospital with functioning ORs, you'll have enough volume. You'll probably be kinda comfortable with them by the third one you put in too. And no, you won't kill anyone by doing it.

This is by far the most WTF thread I've seen here. I hope me or my family never cross these kinda residents.

Again, scary.

Ok good, see if you like it when the urology intern rotating on GI surgery jabs your dad’s NG tube into his nose and throat repeatedly, making him bleed, gag, and potentially aspirate. At least he was a real surgeon and didn’t ask for or need help.

Residents should seek out and acquire new skills, with appropriate supervision when necessary, but know their own deficiencies and limitations. The correct thing to do is to seek help in those circumstances, and use that opportunity to improve one’s skills/knowledge base

 

[Gurby]

You have to function like there's no calvary

That's a heavy Freudian slip right there!

 

[vhawk]

Ok good, see if you like it when the urology intern rotating on GI surgery jabs your dad’s NG tube into his nose and throat repeatedly, making him bleed, gag, and potentially aspirate. At least he was a real surgeon and didn’t ask for or need help.

Residents should seek out and acquire new skills, with appropriate supervision when necessary, but know their own deficiencies and limitations. The correct thing to do is to seek help in those circumstances, and use that opportunity to improve one’s skills/knowledge base

It's a bit of a dishonest way of phrasing it. His point, presumably, was that this "asking for help" is a noble way of framing what is actually going on, which is "making someone else do it." What part of your experience has suggested to you that deferring to other people's knowledge and expertise is a reliable and successful way of gaining knowledge and skill for yourself? Sure in a perfect world but is that what you ACTUALLY think will happen in reality?

"Hubris" clearly has its flaws but at least there is a reliable mechanism whereby it forces people to actually gain the skills and improve. This surgical attitude wasn't like passed down from the gods and it didn't just randomly arise. It evolved as a strategy because it works, albeit imperfectly, and because it demonstrates awareness of the flaws and weaknesses of human nature. If there ISNT an option to defer work to someone else, you have little choice but to learn how to do it yourself. If there is that option to defer, you still could, in theory, learn how to do it yourself, but I could learn Portuguese too.

 

[vhawk]

Although I'm amused by my occasional consult for NGT placement, I quickly decided in residency never to get frustrated or push back on "basic" consults.

People calling in consults want help. There's a lot of macho chest puffing in academic residency (especially amongst surgeons), but I think it's completely reasonable for a physician to place a consult for a procedure they're not comfortable with if they think it's in the patient's best interest.

I'm not arguing that every problem outside your field needs a consult, but every physician has a different threshold on what they feel they can do safely for a patient. And as a consultant, I can't tell what that threshold is for other physicians. So I say "thanks, I'll see them soon".

I completely agree with you and stopped giving any pushback about halfway through pgy2 year, despite what I may have said privately. But IMO, there are basically 3 reasons to consult another physician, only two of which are legitimate.

1. You have identified a problem, the solution to which is outside of your specialty. For example, the ED calls me for acute appendicitis.

2. You do not know what is wrong with a patient or what to do, despite having thought about it as much as you can and looked up everything you can (or less than that if it is a true emergent time is money situation of course)

3. It is not easy, and you are busy, or uncomfortable, or wish to avoid liability and responsibility.

The disagreement in this thread stems from some people thinking OP is in group 1 and some thinking he is in group 3. The problem is that both are right, some of the time. Encouraging "humility" and "teamwork" increases the overall amount of group 3 behavior, because human beings respond to incentives. Encouraging hubris, and toughness, and ego, and "you are all that stands between the patient and death", discourages group 3 behavior.

Both approaches have potential benefits and potential harms. Uniformly encouraging deference and help-seeking is not some free lunch that only has benefits.

But you make the very astute point that, in any given interaction, it's rarely possible to know whether the consulting physician is in group 1 or 3, and so it behooves you to give them the benefit of the doubt, at least until they become serial abusers

 

[doc05]

Ok good, see if you like it when the urology intern rotating on GI surgery jabs your dad’s NG tube into his nose and throat repeatedly, making him bleed, gag, and potentially aspirate.

Exaggerate much?

Every urology intern I've worked with has been an all-star who would've been embarrassed to tell me they couldn't place an ng tube. It's a med student procedure. It may be inconvenient, but let's not pretend it's difficult.

 

[Jolie South]

I disagree with the “ego” argument. I like to be able to handle as many things as I can on my own because events unfold in a more timely fashion and I think it’s better care. I know I can’t do everything and I know what is beyond my skill level. However, putting in an NG, putting in a Foley, doing maneuvers for hyperkalemia, and ordering a basic chest pain work up are all things that I think should be in EVERY physician’s armamentarium. We all need to be able to handle the “first step” in things outside our comfort zone.

I am going to try to bail out the water in the sinking boat not just standing there waiting for the Coast Guard to come.

That doesn’t mean I am going to continue jamming an NG in a bleeding nose, or get a scope for a Foley when the coude trick fails, or not call nephrology at the same time as the maneuvers when a potassium is 6.5. You have to ask for help when it’s appropriate, but I think you have to know what you’re dealing with before you call the consultant.

But this may also be a product of the environment I trained in. Completing residency at county hospitals, a lot of times if I didn’t do things, my patient didn’t get care, be that from nurses or lazy attending consultants who didn’t want to come in in the middle of the night to help take care of uninsured gangbangers.

 

[kitsunepixie]

Interesting thread. As a pediatric neurosurgeon I can't even remember the last time I placed an NGT--probably on my anesthesia rotation as an MS3. I'm pretty good at putting Foleys in tiny humans and preventing a call to Urology after our OR nurses struggle.

I recall during residency our Gen Surgeons calling Neurosurgery a few times to do lumbar punctures. I think that they actually wound up having ID do it since we were all scrubbed in the OR at the time.

Speaking of "consults for basic skills"...I recently saw a kid in my clinic for staple removal (3 staples) for a scalp lac that was repaired at some outside ED. He didn't even have anything neurosurgical -- just the scalp lac. I guess his PCP didn't feel comfortable taking out staples? So he had to drive all the way an hour-and-a-half away to have a specialist take out 3 staples. I felt bad for the family.

 

[dpmd]

I was wondering if these expectations that urology place their own NG tubes holds at the attending level. I guess it's one thing to expect residents to do something at an academic hospital, but what about a private practice urologist?

In the community where I am, nursing will put the NGT and urology will probably consult me to just chime in if things don't quickly resolve. If it is gyn then I am definitely getting the consult. I find all the crap you got initially about being a surgeon who operates on the belly and not knowing how to manage ileus pretty funny since it was common place even in residency for gyn to call us for ileus. However, even there the number of NGT I had to place the entirety of my residency was probably single digit (so good luck to whoever is calling me as the more experience person because I definitely don't do them now -though I would if nursing claimed to fail)

 

[TypeADissection]

We've got it fairly easy here at my institution, where the nurses are quite adept at placing NGTs on our usual surgical floors. Every now and then though, a patient on L&D, palliative or other non-surgical floors requires a NGT and the nurses there aren't comfortable and will ask us to place them. When I was an intern, my chief resident made me place every NGT on the surgical floors and had the nurses page me so I could do it with them because she knew that we had it easy. I now do the same for my interns because a handful of times per year, they're gonna have to do it and "I've never done one" just doesn't fly. This is general slavery and placing tubes in either end of the GI tract is a must.

 

[armybound]

We've got it fairly easy here at my institution, where the nurses are quite adept at placing NGTs on our usual surgical floors. Every now and then though, a patient on L&D, palliative or other non-surgical floors requires a NGT and the nurses there aren't comfortable and will ask us to place them. When I was an intern, my chief resident made me place every NGT on the surgical floors and had the nurses page me so I could do it with them because she knew that we had it easy. I now do the same for my interns because a handful of times per year, they're gonna have to do it and "I've never done one" just doesn't fly. This is general slavery and placing tubes in either end of the GI tract is a must.

any tips for butt tubes?

 

[dpmd]

any tips for butt tubes?

Lots of lube and don't accidentally put it in the vagina. Vice versa applies too.

 

[ThoracicGuy]

Lots of lube and don't accidentally put it in the vagina. Vice versa applies too.

This sounds like the start of a story in the Lounge...

 

[OtoHNS]

Interesting thread and an important topic that doesn’t get thoughtfully discussed very often, especially by the caliber of people who’ve posted here.

Some tricks I’ve used to make it easier:
1) do a basic exam of the nose and pharynx. If one side of the nose looks jacked, try putting the tube on the other side. Try to notice the big pharyngeal mass before ramming a tube into it.
2) numb and decongest the nose. I carry a spray bottle of a tetracaine/afrin combo to use for adult endoscopy and it makes the NG experience much better. pharmacy will also make this when asked.
3) if not contraindicated, I’ll frequently numb the pharynx with a small spray of cetacaine as well. I find this especially helpful for gagging patients. If I ever need one, I’m spraying this on myself.
4) put some lube on the tube
5) stay on the floor of the nose. This ends up feeling like you’re aiming slightly inferiorly. All the “we can’t get it” consults have failed at this step. It doesn’t take much angling superiorly before you’re ramming into the middle turb.
6) put the biggest tube in that you can. I find them easier to place and they are less likely to get clogged. The only thing that sucks more than getting an NG tube is getting 2 NG tubes.
7) secure the tube. I personally like those little magnetic bridles that loop a tie around the septum.

Good tips. I also got consulted every once in a while in residency days for "difficult" NGT placement.

One trick that almost always worked for me was to sit the patient up straight and have them tuck their chin to their chest once you've advanced the tip of the tube past the nasopharynx. This improves the angle and makes it less likely that the tube will go into the trachea. Once they've tucked their chin, I would just say "swallow swallow swallow swallow swallow..." and advance the tube and almost always it would go right down.

 

[TypeADissection]

This sounds like the start of a story in the Lounge...

Ooh nasty. Go on...

 

[DoctwoB]

Exaggerate much?

Every urology intern I've worked with has been an all-star who would've been embarrassed to tell me they couldn't place an ng tube. It's a med student procedure. It may be inconvenient, but let's not pretend it's difficult.

Well yes I’m exaggerating. Most will go just fine. But a few won’t. Like most things in medicine or surgery, it is an easy procedure until it isn’t.

FWIW I do believe that we should be attempting placement, even if the nurse fails, prior to calling for help. I also believe that we shouldn’t hesitate in calling for help if it may be in the patients best interest (e.g high aspiration risk)

 

[Trauma Surgeon]

Well yes I’m exaggerating. Most will go just fine. But a few won’t. Like most things in medicine or surgery, it is an easy procedure until it isn’t.

Yeah, until it isn't….
Skeptical Scalpel: Fatal internal jugular vein cannulation by a misplaced NG tube

 

[cpants]

Yeah, until it isn't….
Skeptical Scalpel: Fatal internal jugular vein cannulation by a misplaced NG tube

Wow that is terrifying. I am making the nurses put em in from now on...

 

[LucidSplash]

Good tips. I also got consulted every once in a while in residency days for "difficult" NGT placement.

One trick that almost always worked for me was to sit the patient up straight and have them tuck their chin to their chest once you've advanced the tip of the tube past the nasopharynx. This improves the angle and makes it less likely that the tube will go into the trachea. Once they've tucked their chin, I would just say "swallow swallow swallow swallow swallow..." and advance the tube and almost always it would go right down.

Hey this is what I do! And I’m not even ENT. I’m counting this one as a win.

 

[dpmd]

Hey this is what I do! And I’m not even ENT. I’m counting this one as a win.

This is what everyone SHOULD do. That and feed the ****ing thing far enough in to actually be in the stomach and not the ge junction (my biggest pet peeve is coming in the next morning to discover a very distended belly and minimal output because the tube isn't in far enough)

 

[LucidSplash]

Speaking of NGTs, I don’t know how to write orders any clearer that my aortomesenteric bypasses keep their NGT in and on LIWS and strict NPO no clamping no meds unless the vascular fellow or attending orders otherwise. why are intensivists and nurses and the whole hospital trying to find loopholes in this order?

 

[deleted547339]

Speaking of NGTs, I don’t know how to write orders any clearer that my aortomesenteric bypasses keep their NGT in and on LIWS and strict NPO no clamping no meds unless the vascular fellow or attending orders otherwise. why are intensivists and nurses and the whole hospital trying to find loopholes in this order?

Because most surgeons have the knee jerk reaction to make everyone strict NPO forever.

 

[LucidSplash]

It’s POD1 and it is putting out 1L a day. Stop telling me he is having flatus.

 

[AtomicKitten9]

I don't think anyone is saying you should cowboy up and do things you're not comfortable with. I think people are saying you should be concerned that you don't feel comfortable managing a post op-ileus as a surgeon that operates in the abdomen.

Also, what's keeping you from learning how to place an NGT? At our hospital, nurses know how to put in NG tubes and are able to. But that doesn't keep any of the interns from doing it - there's no rule that only nurses can do it. You want an NG tube in your patient? Go put it in yourself - that is how our interns learn. This is true for any patient procedure. As a general surgery resident, we get calls from medicine doctors asking for us to put in NG tubes and we say no. We aren't there to do your scut work just because you don't want to learn how to put in an NG tube yourself. It's the exact situation here with urology and foley placement - urology asks if the physician has tried to place a foley prior to attempting it themselves. So you better believe that if a nurse if having trouble placing one, I do it myself before calling urology. It's saved me from only ever calling them once, and in that situation I watched to see what they did that could help me.

I would take this patient experience as a wake up call to learn how to do it.

 

[balaguru]

Yeah, until it isn't….
Skeptical Scalpel: Fatal internal jugular vein cannulation by a misplaced NG tube

A few years ago I was consulted on a patient incidentally found to have the tip of the NGT in an extraluminal position on CT scan. I found that it had perforated into the retropharyngeal space via the nasopharynx and was pushed down below the diaphragm somehow. Had he gotten tube feeds or meds it probably wouldn't have ended well for him. I placed it on suction for a short time and then pulled it. He did fine.

 

[Jolie South]

As an intern, I got asked by random seniors to place Dobhoffs all the the time without supervision because nurses weren’t allowed. I mean I had gotten “signed off on NGs” as a student so I wasn’t totally clueless.

Once, I lodged a Dobhoff in someone’s right mainstem. During placement the guy was coughing, but not more than usual. Like a good intern, I checked an x Ray before feeding the guy. Immediately pulled and placed it appropriately.

I also once successfully cannulated D4, which never happens. Hahahahaha

 

[Kissmyabjj]

As an intern, I got asked by random seniors to place Dobhoffs all the the time without supervision because nurses weren’t allowed. I mean I had gotten “signed off on NGs” as a student so I wasn’t totally clueless.

Once, I lodged a Dobhoff in someone’s right mainstem. During placement the guy was coughing, but not more than usual. Like a good intern, I checked an x Ray before feeding the guy. Immediately pulled and placed it appropriately.

I also once successfully cannulated D4, which never happens. Hahahahaha

Yep. Happened to me too.