I worked in a trauma center years ago and the residents also covered the VA hospital up the hill from us.
One evening the neurosurgery resident was in the ER placing a ventriculostomy and a Codman drain on a patient with a head injury so I was holding his beeper and answering his pages.
First I get one from the VA. A nurse up there is calling to say she needs him to come and verify NG tube placement on a patient she had placed a NG tube in. WTF????? For the uninitiated, an NG tube is a naso-gastric tube. It is a long, flexible tube that is inserted through the nostril, down the throat, into the esophagus and the end sits in the stomach. It can be used to suction stomach contents out or the put tube feedings and meds into the stomach. Placement is checked to make sure it isn't in the lung as putting formula etc. in the stomach is NOT good. This is a nursing task. You check by injecting some air and listening for a gurgle over the stomach and by aspirating some stomach contents. You can also get an x-ray. So, I'm confused. I ask her, "You don't check your own tube placement." She tells me no. And this tube is going to be used for feeding. So you are putting stuff into the tube and not checking yourself for placement before each use? Are you crazy. So you don't check placement and infuse tube feeding into someone's lung which will surely kill him? Not to mention the fact of the prolonged delay in starting nutrition, which is crucial to healing, while you wait for the one resident in the hospital to have time to trot all the way over there and do that for you. I am flabbergasted but tell her I will pass on the message.
Before too long I get another call from another nurse on another floor there at the VA. She has a patient that is post op from back surgery and she can't find his orders. Well come to find out, the patient came out of surgery nine hours ago! The patient has been on the floor for NINE hours and no one has looked for the orders until now? Once again, WTF?
My dad told me awhile back that he was going to try to sign up for VA benefits so that he could save some money on his meds. I looked them over and almost all of them were on Wal-Marts $4 prescription list and two of the others could be changed to ones on the list. I talked him out of signing up for VA hell.
This is how the country is treating it's Veterans, what a crime.
Monday, January 21, 2008
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I'm in Australia and work in large public hospital in an ED, Regarding NG tubes our hospital policy is that i can put it in and 2 nurses check the placement. But nothing can be put down the tube untill documented Xray confirmation by doctor!! which ia such pain and delays treatment all the time.
This sounds like a lesson from a crazy prof I had. She said you check NG placement with an x-ray, mark the tube, then so long as it hasn't moved, you never have to check it again.
Right.
Except that's not how it works in the real world.
It's been a crime for a LONG time... They killed my Dad in 1959 by doing open chest surgery, then putting him in an airconditioned room without an oxygen tent, gave him pneumonia, then didn't monitor his lungs. His left lung filled with fluid and collapsed on his heart...
Even though I'm a Veteran, I will never use the VA.
The VA hospitals frighten me. They don't have anywhere near what they need. And yet, their funding has been cut over and over again in the past few years.
My dad used them years ago and my husband could really benefit from the VA system now, but it scares the hell out of me.
That is truly scary. We send our kids home with NG feeds all the time. We teach the parents/caregivers how to 'drop' the tube and check for placement. I can't imagine trying to teach a parent that all you need to to check is to listen for air and aspirate contents, yet when I, as a nurse do it, I need a doctor and an xray? What kind of credibility would I have? And, how could I possibly help the parents become confident that they could do this themselves. I guess everytime they put a new tube in, they could go to the ER to have placement verified by xray and a doctor, right?
We use small bore feeding tubes that sit in the duodenum for feedings (we only use NGs for suction). They need to be placed by an MD, x-rayed to confirm placement (post pyloric), and then the MD has to come and remove the stylet. In the mean time, you can't give meds, start feedings, nothing. It's the worst when patients pull them out. Sometimes it takes a whole shift to get a new functioning tube in them.
The rationale, as I understand it, is that the post-pyloric tubes put the patient at lest aspiration risk, but it's a pain in the ass when you have to give IV diuretics or labetolol (the only antihypertensive we can push on my non-monitored unit) because the patient missed their lopressor because they pulled their tube and can't swallow and their diastolic BP is 110.
Melissa, at my hospital the nurses place those tubes and most of the nurses have taken training to read the post placement xray. If two certified nurses agree that the tube is in the right place then it is good to go.
That's awesome. Come to think of it, we aren't even allowed to drop NGs on the adult floors, has to be an MD. Honestly, my theory is that they don't let RNs do these basic things because they want the interns to learn (on my floor, for the longest time drawing blood off PICCs had to be done by MDs....yeah, asinine, only reason we do it now is because the MDs complained that it was asinine).
It's maddening because it delays the hell out of everything. I had a dysreflexic quad with toxic megacolon and an ileus just blowing up one night (BPs all over the place, couldn't breathe, you get the idea.) Took me four hours to get the intern to drop the NG to decompress them, which they weren't even going to do until I pointed out his history of dysreflexia (the reason for his labile BPs) and the fact that they could, you know, perf at any time.
Gotta love teaching hospitals.
Anyway, my apologies for the tangent. Back to commenting on your original post. Yikes. And shame on them. That is all.
I'm a 4th yr med student in the mil system - I've seen how the VA system works up close and find it appalling.
Many patients utilize both VA and "regular" mil system (esp in emergency situations- adding just that much more spice to the mix) and there is almost no crossover btwn systems --- I'm going into internal medicine and have worked in several ICUs now and this a nightmare.
When we have a VA pt come to us thru the ER, we have almost no ability to access their previous history/med list (and most are on 9 zillion meds with a PMH as long as I am tall but the pt knows none of it - "some heart trouble", and their med list consists of "a little blue one that I take twice a day and a large red one I take sometimes").
Depending on the hospital, there is sometimes a VA doc that visits the mil hospital once a week, and you can call that doc (-yeah, have fun with that and let me know how it works out for you-) or hope to catch him/her in the hallway. There's also a rumor that "a resident, but I'm not sure which" has a password to the VA computer system.
It's a friggin computer system people - you trust me with the military computer system, but not the one with the VA???? And while I'm on that topic, why is our primary system still DOS-based????
OOOOOOOOOhhhhhhhhh, I'm sure I'm already hypertensive, with a loooooong career in front of me.
Last but not least - this is the system we're dumping our newest triple amputee/60% TBSA/TBI status-post hemicraniectomy 18 year old veterans for a LIFETIME of care.......
Are there words for this?
Trauma center with a VA hospital just up the hill both of which covered by residents...
Did you work in Pittsburgh?
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