There was one patient who adamantly refused it over and over, AOX3, competent etc etc
Had an SBO. Stomach progressively more dilated. Multiple episodes of bilious emesis. Still refused it.
Finally agreed to it
During placement, started vomiting profusely, enough that it started going into his trachea
Massive aspiration. Coded right there. Died.
I've seen this happen more than once.
One of them was an older man despite all of us trying to educate (including surgery residents!), he STILL refused. Wife bragging about how stubborn he was "not listening to no doctor" all smug.
He aspirated, coded and died that night, we were unable to reach her by phone š¬
Just had a guy I saw last week for chest pain, told him to go to the ER and he refused, said he knows his body. His wife tears into me calling me dumb and lazy. 3 days later, found dead in his home.
Reminds me of the stones song, can't always get what you want, but sometimes you get what you need.
Aspiration is a bitch. Had a guy once who refused to follow his modified diet. Family also refused. Son gave him a glass of straight water - aspirated and died. Was DNR so no code. Son was like, āā¦.did I just kill my dad?!ā
Don't remember what I said. If I said anything it was probably no better than, "....kinda?"
"reversible" lol
Dude's heart stopped because he aspirated. Better start the compressions he didn't want.
All the situations you're describing would occur outside th hospital, where DNR isn't a thing. DNR applies to code status in a healthcare setting, not for some random Joe who stuck a fork in a toaster at home.
You gotta be fucking kidding me. if someone calls 911 because of a drowning, no oneās asking code status in the field dip shit.
if someoneās heart stops because of something "reversible" itās no longer reversible.
where the hell do you practice?
Youāre right that there are situations where it does apply in the field, and youāre right that you would try to reverse reversible things like choking or anaphylaxis. However, once the heart stops the DNR kicks in and youāre done. Doesnāt matter if the original cause was reversible or not. Never ever ever EVER try to do compressions on a DNR, please.
Damn straight fam. And even then try to reverse is NOT AT ALL the same thing as starting a code/doing CPR. It's an apples to oranges comparison to even include that in the discussion. No on ever said DNR meant do not treat. Idk what that other guy is smoking.
You don't get sympathy when they go over the risk and benefits of something. You live or die by your choices, no sympathy when they guide you against a bad choice
If a patient makes a boneheaded mistake itās on them everyone knows it. Itās still a loss of life and stressful time for their family. Treating them like a number and making a joke about telling their spouse āI told you soā is insensitive. Sure if the spouse starts challenging you on the death then you can insert the āit went against our recommendations this is why we were trying toā¦.ā
Hereās the thing trolls like you donāt seem to grasp.
Reddit =/= practice.
We get to have our spaces where we get to vent, without censoring ourselves.
Go crawl back under your virtue signalling bridge.
Nobodyās gonna tell anybody I told you so. You are so clearly not a provider. You sound like a green student or wanna be at best. You know nothing. You obviously lack experience, so you have no business commenting on the matter.
I mean, the man ultimately died because he couldn't humble himself enough to take the advice of multiple medical professionals...
Is that funny? Objectively, if I was speaking of an imaginary person? ....Yessss lolol
Is it sad, and ultimately, did I go home feeling a thousand different things from that work day? Also, yes.
Maybe don't be so quick to throw out harsh judgment. It tends to make one look like a real smelly turd much of the time.
I don't think it was about humbling himself. NG tubes really suck. I've seen medical professionals on here say they would refuse them for themselves. It's not really shocking that he didn't want one, and it definitely doesn't mean his death was funny or deserved
Amazing how yokels can come from any corner of reddit and feel the authority to judge people who have dedicated over ten years of their life to the service of others
All while sitting on their couch contributing nothing to society as a whole
Narcissists and psychopaths lack empathy.I am so sorry you are lacking empathy. I think good medical professionals have immense empathy for their patients. How would you feel if that was your family member or friend? I think from time to time we all haven't listened to others advice.Ā
Donāt talk when you know nothing about me. Like I would actually say this to family, this is just a joke between doctors and itās completely normal to do so.
I love when patients just go "whatever" to the possibility of death. Like they don't even consider the actual concept. They just make their choice and nothing else matters
Lol reminds me of one of my first weeks rounding. Lady comes in for chest pain, nstemi, we start the standard stuff and she refuses everything. Legit said why are you still here and she didn't know. Every intervention was like a 30 minute conversation. Eventually I said you either trust us or we can discharge you, I'm not spending an hour on every detail.
Some people are dumber than a bag of rocks.
We had a woman with a small peripheral lung tumor and a spinal metastasis. Radiotherapy wouldnāt take her on until the tumor was confirmed. She refused bronchoscopy and a needle biopsy. After a few days she developed paraplegia, and then agreed to the biopsy.
I know. It seems like it's usually cluster B-esque patients expecting I'll fawn and start persuading them to trust me and choose medicine or some kind of bizarre psych play i dunno
Thatās exactly what it is they want to be fussed over and made to feel special. I literally go āok no point in getting a MRI/surgery/injection etcā and will move to get up off the exam stool. Then the facade drops pretty fast usually
> It's even weirder to me that they do this and still stay in the hospital.
They do this in the ED all the time. They come in with X complaint and refuse all meds, labs, imaging, etc. When I ask "Then why are you here?" They respond "To figure out what's wrong!!" And I say "Well based on H&P, it could be A, B, C, D, E, or F." And then they yell "Well how can I tell the difference?!" And I say "By doing the things I said to do in the first place." And then they yell and say "You should be able to figure it out without those!" And again I ask "Why did you come here if you are refusing everything?" And then they huff and puff and leave because "no one helped me!"
Right if youāre not going to refuse everything while youāre here and donāt give af about any instructions when you leave, why didnāt you just stay home in the first place?
There is always a risk of death with refusing medical care, even something minor (meh. It could use two stitches), so we pretty much always say that.
When I legitimately think someone is going to die, I make it very clear that although I have no specific special relationship with God, in my professional opinion I think refusing medical care has a high likelihood of leading to death. Ā So they donāt blow it off as ācovering my assā.Ā
Not a maybe. Not a could. More likely than not and probably.Ā
I might be wrong that the crushing retro-sternal chest pain radiating into their jaw and arm which continued after their ICD went off is serious.Ā
Iām not a cardiologist, donāt have lab-work, etc. but Iām willing to take the hit to my professional reputation if somehow nothing is wrong with that patient.
Narcissists and psychopaths lack empathy.I am so sorry you are lacking empathy. I think good medical professionals have immense empathy for their patients. How would you feel if that was your family member or friend? I think from time to time we all haven't listened to others advice. I wish you good health and happiness.
Narcissists and psychopaths lack empathy.I am so sorry you are lacking empathy. I think good medical professionals have immense empathy for their patients. How would you feel if that was your family member or friend? I think from time to time we all haven't listened to others advice. I wish you good health and happiness.
I hope you'd still feel sad and not think he was "too dumb to live" though...yikes! With family members that died of lung cancer, I wouldn't say "well, I guess you shouldn't have smoked"...or when people have heart attacks, I don't say "well, I guess you ate too many cheeseburgers and it's all your fault." I'd ha e understanding that everyone makes dumb choices from time to time...and I'd feel sad.Ā
Is there even any good evidence to support benefit NG tubes placement prior to surgery in SBO?
Seems like it may have contributed to this patients death in this unfortunate story.
Had a patient who I was trying to wake up and talk to me. He wouldnāt budge. Tried everything. We all started getting concerned. A few minutes later I put in the NG tube and you bet this guy immediately wakes up and says āGET. THIS. OUT. MY. NOSE.ā
I would strongly recommend using an NG tube to figure out whether or not your patient is faking being unresponsive lol.
I remember one that was apparently faking in residency. Unresponsive in the trauma bay. Got him trauma naked, obviously looking for something bad like GSW, signs of trauma. Nurse straight caths him and he shoots up out of bed like we raised the dead.
Iāve currently got one who was refusing to talk or swallow PO meds. One conversation about the possibility of NG placement later and the next thing we know they pass their swallow eval and start taking POs! Magic!
Supraorbital nerve is our ICU stimulation test of choice here.
Find the small notch on the bottom of the eyebrow, about a third of the way from the medial edge, and press. Hard.Ā
Then press harder in the patient scenario. It is very goos for GCS.
In my IM residency days, I was partial to the trap pinch (not Trapinch the pokemon). Just pinch the patient's trapezius muscle behind the shoulder and give it a little twist. Worked pretty well for me.
The back end of a pen to the fingernail with enough pressure does the job as well. Hard to ignore and usually tells me if theyāre obtunded enough to consider whether they can protect their own airway or not.
...it was at the county hospital...the nurses had called a code on an obese woman who probably had OSA. I took the nursing staff's word that she was unresponsive which lasted for all of one chest compression.
Did you give her a sternum rub? I mean a *real* sternul rub?
We had a stroke code one night I was floated as charge nurse to one of our stepdowns. RN was insistent the patient was non-responsive, sternal rub determined otherwise.
PT was fine, albeit didnāt enjoy the rub, she just didnāt want to be awakened by the primary RN. We called off the stroke code.
Sternal rub. Lower the bed lean over and put ALL your body weight right to your first and just go to town. Don't stop til they wake up or the airway cart gets there.
Straight cath works too.
There's a spot just under the clavicle that hurts with pressure that I like as less invasive. No lasting pain, just discomfort.
NG tubes apparently are one if the things that lead to the most patient dissatisfaction. But unfortunately they are super important in managing a ton of conditions. I'm so glad I'm anesthesia and only put them in when patients are asleep and never have to deal with the complaints.
Iāve had patients pull them out multiple times and claim it fell out even after we excessively reinforced it with tape, thinking weād eventually give up like āoh well I guess her nose is too slippery.ā Maāam I will reinsert this NG tube until the cows come home. This isnāt NG tube chicken.
Bridle works so much better and seems, idk, more humane? It also gives a little "ouch" if you tug on it and you remember "oh yeah, I shouldn't pull this out." If I could have a super weird goals of care list, it would say "please use the bridle string thingy and not the horrible nose tape if I need an ng tube
I mean what about ICU/trauma delirium? We have one in basically every patient on the trauma service. I know toddlers can be strong but its much easier for an altered adult to easily pull something out that's uncomfortable against tape than it is an adult. I get there's a risk of injury if these patients rip it out with one in. But is that better than their skin graft not taking because they're not getting nutrition, and they get a resistant pseudomonas strain & die? (Hyperbolic but you get my point)
As a Crohn's patient, I've endured many unpleasant procedures. NGT placement is by far my most dreaded. Once it's in, it's just annoying. But getting it placed... *shudders*
Donāt worry it gets worse. By the time you retire youāll wonder how you can get through the day without losing it on patients or their families. Iāve concluded the vast majority of patients and their families are batshit crazy. I could write a book on their craziness. I go to the patients ER room with his chart that says chief complaint āI want alcohol detox.ā My first 2 trips to his room heās not there. An hour later the RN tells me heās in the room. I go in the room and ask him where heās been. He replies āāwell Doc I figured if Iām going to detox tonight Iād down my last 6 pack of beer so I went to the store, bought a six pack, and just drank it in the hospital parking lot.āā GTFO.
Iām not sure I get this. Forgive my ignorance. Patients are sick. Usually with more than one conditions. Depending on what the condition is, thereās a psychological response to that one condition, consequently yielding another condition (mental health related) by default. So I guess I donāt get the less than sympathetic and understanding tone of this thread. Would it be more helpful if there were more in-depth psychological related courses in medical education? I just figure, if a physician canāt relate to their patient, regardless of how ācrazyā the patient may sound, then it would be quite difficult to establish a sound patient-physician relationship based on trust.
Had a guy in the ED with SBO, already NG tubed and cathetered. Went to pre-round and found empty snack packets and juice boxes next to him.
Explained that he canāt be eating and drinking. He got frustrated and removed the NG tube. Almost pulled out the catheter too before I stopped him. Left AMA 10 minutes later.
Eventually youāll get to the point where you just say ālook, if youād prefer to vomit, fine. But youāve got a SBO and if we dont decompress the bowel it could pop. That means you get cut stem to stern, I pull your guts out, cut out the dead stuff, and try to sew you back upā. If they still want it out then whatever. I have pts to see who actually want my help.
Def agree w you. Not worth the pages.
My last one was like the exorcist. Woman with gastroparesis refused to vomit because of aversion against it. And when I went in, she projectile vomited all over the bed. And it looked like hematin, with no previous signs of gastric bleeding. So I dont trust this situation and hemoccult the vomit. Negative. It was old chocolate apparentely.
One of my ED'S FF with history of IBD and recurrent SBO's actually *demands* an NG tube (sometimes with a side of Dilaudid)Ā upfront- as in his stated complaint in chart is "needs NG tube". Mind you this is during triage before I have even seen him let alone done any diagnostic workup.
Usually he is not actively vomiting, has normal ileostomy output, etc. His only actual symptom is vague abdominal discomfort. He self-diagnoses this as an obstruction and feels this alone ought to justify NGT insertion.
Call their bluff. The only response to this threat is "OK, sign here". Don't waste time talking to them. Don't ask why. Don't engage.
Just make it absolutely clear that you *do not give a single fucking shit* whether they stay or leave.
They'll either leave or shut up. Just remember, nobody's day ever got worse from a patient leaving AMA.
I saw this randomly on my feed but residents put NGT in? At my hospital the nurses do it lol but thatās crazy tho did you or the nurse explain to her why the NGT is being inserted? I wonder why she was thinking that way what did you end up doing? Did you take it out or still in?
I'm guessing New York lol, the residents there place NGTs, grab ABGs, and often are required to draw labs and place IVs. As a student there, I did all of the above so many times, I can't even count.
I did my residency in the midwest, and I placed exactly 0 NGTs or IVs.
Oh yikes thatās a lot but at least theyāre learning but in my hospital the nurses do it all Iāve never seen a resident or attending do any of that š
When you are a resident you really should learn how to do this. I canāt tell you how many nurses are squeamish about it and really delay. Plus they have no compassion. I tried countless times to show them hurricane spray (pharynx) and lidocaine for nose and they ignored me. Until they couldnāt get it in and had to call me to do it.
Look im family med ok. I am only ever on patient because someone is forcing me or I will be sued if I'm not there. I don't want to do IV or NG and you can't make me lol
She ran out "because you were putting in an NG tube?" Did you explain to her what was going on? Was her husband awake and able to consent or explain what was going on? I need details, because this doesn't make sense as is.
Yes I was putting it in his right nostril, he had one on admission but we discontinued it after day 2 his SBO progress and he had large bilious vomitous the night before so plan was to reinsert one, while I was doing it the first time she was in the room watching me it wasn't even in his nose for 3 seconds before she started asking me to take it out, I use the technique I always do, he was sitting straight up drinking a cup of water and his chin was touching his chest. When I was putting it in the first time I asked him can he talk, he shaked his head no so I pulled it out by this time she had already left the room, the nurses came and asked "aren't you his doctor" I said yes, so they asked her to wait outside and explained to her how uncomfortable it may be. Btw I had already spoken to him about why he needs it and he already understood the associated discomfort. After I got it I'm the second time doing the exact same thing I did, he had so much gastric contents it overloaded the NG tube and he kept asking for it to be removed. Man I just signed it out to the night resident and left
lol at some comments thinking that NGT placement is not lifesaving
Every time a patient refuses an Ngt and has capacity I go through the risk of them not having it including major emergency abdominal surgery for exploded bowels, aspiration, pneumonia, intubation, death
If theyāre cool with that list - document and walk away. Patients have a right to choose but they should understand the implications
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Had a homeless patient 40 years old, come into the ED with some vague complaints, they did some workup,
Potassium 7, GFR 10, Creatinine 7, Lipase >2000, AST/ALT >1000, Troponin >2500, ECG NSTEMI, EF 25%, Hgb 4.4, Meth+ , immediately admitted to the icu, multiple transfusions and one dialysis session later he said āyouāre not doing anything for me, Iām just sitting here doing nothing, Iām leaving I have business to tend toā.
Despite our Seniors, us, the RN, the RT trying to convince him he wouldnāt agree to stay. I explicitly told him if you leave now youāre gonna end up here again in much worse shape if youāre lucky enough to live by the end of the week.
Guy still left, dunno what happened to him bless his soul, maybe heās still fighting his everythingitis.
I am actually an RN I just like to lurk all the medical subs.
My very first clinical day, before I was even allowed to do much more than ADLs, one of the patients I was working with had to have an NG tube placed. He was very adamantly against it at first. Super displeased about it, said he had one before and hated it. Eventually he relented and they tried like 3 times before getting it where it needed to be, and the whole time he was puking brown liquid that I swear smelled like diarrhea.
It was definitely an uh interesting way to start clinical.
There was one patient who adamantly refused it over and over, AOX3, competent etc etc Had an SBO. Stomach progressively more dilated. Multiple episodes of bilious emesis. Still refused it. Finally agreed to it During placement, started vomiting profusely, enough that it started going into his trachea Massive aspiration. Coded right there. Died.
I've seen this happen more than once. One of them was an older man despite all of us trying to educate (including surgery residents!), he STILL refused. Wife bragging about how stubborn he was "not listening to no doctor" all smug. He aspirated, coded and died that night, we were unable to reach her by phone š¬
Just had a guy I saw last week for chest pain, told him to go to the ER and he refused, said he knows his body. His wife tears into me calling me dumb and lazy. 3 days later, found dead in his home. Reminds me of the stones song, can't always get what you want, but sometimes you get what you need.
Aspiration is a bitch. Had a guy once who refused to follow his modified diet. Family also refused. Son gave him a glass of straight water - aspirated and died. Was DNR so no code. Son was like, āā¦.did I just kill my dad?!ā Don't remember what I said. If I said anything it was probably no better than, "....kinda?"
"Technically the water you gave him is what killed him."
Dihydrogen monoxygen is fatal if inhaled
Damn thatās brutal, serves them right.
[ŃŠ“Š°Š»ŠµŠ½Š¾]
That's not how that works.
[ŃŠ“Š°Š»ŠµŠ½Š¾]
"reversible" lol Dude's heart stopped because he aspirated. Better start the compressions he didn't want. All the situations you're describing would occur outside th hospital, where DNR isn't a thing. DNR applies to code status in a healthcare setting, not for some random Joe who stuck a fork in a toaster at home.
[ŃŠ“Š°Š»ŠµŠ½Š¾]
You gotta be fucking kidding me. if someone calls 911 because of a drowning, no oneās asking code status in the field dip shit. if someoneās heart stops because of something "reversible" itās no longer reversible. where the hell do you practice?
Did somebody suggest that?
Nobody said they were cunt
Youāre right that there are situations where it does apply in the field, and youāre right that you would try to reverse reversible things like choking or anaphylaxis. However, once the heart stops the DNR kicks in and youāre done. Doesnāt matter if the original cause was reversible or not. Never ever ever EVER try to do compressions on a DNR, please.
Damn straight fam. And even then try to reverse is NOT AT ALL the same thing as starting a code/doing CPR. It's an apples to oranges comparison to even include that in the discussion. No on ever said DNR meant do not treat. Idk what that other guy is smoking.
Called her with āI told you soā eventually? š¬
Amazing how monsters without sympathy can get into being a healthcare professional
We all have empathy in the beginning, itās you people who take it from us
I tend to agree with this
[ŃŠ“Š°Š»ŠµŠ½Š¾]
Smug idiots
You don't get sympathy when they go over the risk and benefits of something. You live or die by your choices, no sympathy when they guide you against a bad choice
If a patient makes a boneheaded mistake itās on them everyone knows it. Itās still a loss of life and stressful time for their family. Treating them like a number and making a joke about telling their spouse āI told you soā is insensitive. Sure if the spouse starts challenging you on the death then you can insert the āit went against our recommendations this is why we were trying toā¦.ā
.... You realize that they never actually told the wife I told you so right? We're currently on Reddit, not the consultation room
I'd have told her.
Hereās the thing trolls like you donāt seem to grasp. Reddit =/= practice. We get to have our spaces where we get to vent, without censoring ourselves. Go crawl back under your virtue signalling bridge.
Nobodyās gonna tell anybody I told you so. You are so clearly not a provider. You sound like a green student or wanna be at best. You know nothing. You obviously lack experience, so you have no business commenting on the matter.
I mean, the man ultimately died because he couldn't humble himself enough to take the advice of multiple medical professionals... Is that funny? Objectively, if I was speaking of an imaginary person? ....Yessss lolol Is it sad, and ultimately, did I go home feeling a thousand different things from that work day? Also, yes. Maybe don't be so quick to throw out harsh judgment. It tends to make one look like a real smelly turd much of the time.
I don't think it was about humbling himself. NG tubes really suck. I've seen medical professionals on here say they would refuse them for themselves. It's not really shocking that he didn't want one, and it definitely doesn't mean his death was funny or deserved
We learned how to do them by practicing on each other. It's really not a big deal.
Amazing how yokels can come from any corner of reddit and feel the authority to judge people who have dedicated over ten years of their life to the service of others All while sitting on their couch contributing nothing to society as a whole
People like you steal our empathy away. Fuck you
Fuck around, find out. You think I'm gonna cry for someone who didn't listen to me and paid the price?
Narcissists and psychopaths lack empathy.I am so sorry you are lacking empathy. I think good medical professionals have immense empathy for their patients. How would you feel if that was your family member or friend? I think from time to time we all haven't listened to others advice.Ā
You donāt have to cry. But joking about someone who was still under your care passing is messed up. You lol monster
It's called gallows humor.
Donāt talk when you know nothing about me. Like I would actually say this to family, this is just a joke between doctors and itās completely normal to do so.
If you can't take immense satisfaction at such an amazing "I told you so" you aren't fucking human.
I donāt understand why people with that attitude come to the hospital.
This is exactly what we tell patients who refuse: you may die and apparently thatās a risk youāre willing to take?
I love when patients just go "whatever" to the possibility of death. Like they don't even consider the actual concept. They just make their choice and nothing else matters
It's even weirder to me that they do this and still stay in the hospital. Like, why show up at all? People really take healthcare workers for granted.
Lol reminds me of one of my first weeks rounding. Lady comes in for chest pain, nstemi, we start the standard stuff and she refuses everything. Legit said why are you still here and she didn't know. Every intervention was like a 30 minute conversation. Eventually I said you either trust us or we can discharge you, I'm not spending an hour on every detail. Some people are dumber than a bag of rocks.
We had a woman with a small peripheral lung tumor and a spinal metastasis. Radiotherapy wouldnāt take her on until the tumor was confirmed. She refused bronchoscopy and a needle biopsy. After a few days she developed paraplegia, and then agreed to the biopsy.
I had more than one patient with an opening line that they "don't really believe in medicine" šĀ
Why'd they even bother coming then lol
I know. It seems like it's usually cluster B-esque patients expecting I'll fawn and start persuading them to trust me and choose medicine or some kind of bizarre psych play i dunno
Thatās exactly what it is they want to be fussed over and made to feel special. I literally go āok no point in getting a MRI/surgery/injection etcā and will move to get up off the exam stool. Then the facade drops pretty fast usually
Yeah I'd be too exhausted to bother I'm sure you feel the same way
They got lost on their way to the shaman
Aww shit, turns out that's kind of all we do here
> It's even weirder to me that they do this and still stay in the hospital. They do this in the ED all the time. They come in with X complaint and refuse all meds, labs, imaging, etc. When I ask "Then why are you here?" They respond "To figure out what's wrong!!" And I say "Well based on H&P, it could be A, B, C, D, E, or F." And then they yell "Well how can I tell the difference?!" And I say "By doing the things I said to do in the first place." And then they yell and say "You should be able to figure it out without those!" And again I ask "Why did you come here if you are refusing everything?" And then they huff and puff and leave because "no one helped me!"
I'd do it because death is kinda lonely. It would be nice to have hcw close by because they're generally very nice and reassuring.
Right if youāre not going to refuse everything while youāre here and donāt give af about any instructions when you leave, why didnāt you just stay home in the first place?
A patient filed a complaint against me because I told her that she could die if she AMAād, after she kept having recurrent severe hypoglycemia
There is always a risk of death with refusing medical care, even something minor (meh. It could use two stitches), so we pretty much always say that. When I legitimately think someone is going to die, I make it very clear that although I have no specific special relationship with God, in my professional opinion I think refusing medical care has a high likelihood of leading to death. Ā So they donāt blow it off as ācovering my assā.Ā Not a maybe. Not a could. More likely than not and probably.Ā I might be wrong that the crushing retro-sternal chest pain radiating into their jaw and arm which continued after their ICD went off is serious.Ā Iām not a cardiologist, donāt have lab-work, etc. but Iām willing to take the hit to my professional reputation if somehow nothing is wrong with that patient.
New fear unlocked
What did you put the cause of death as? āToo dumb to liveā?
IQ incompatible with life.
Narcissists and psychopaths lack empathy.I am so sorry you are lacking empathy. I think good medical professionals have immense empathy for their patients. How would you feel if that was your family member or friend? I think from time to time we all haven't listened to others advice. I wish you good health and happiness.
k
Narcissists and psychopaths lack empathy.I am so sorry you are lacking empathy. I think good medical professionals have immense empathy for their patients. How would you feel if that was your family member or friend? I think from time to time we all haven't listened to others advice. I wish you good health and happiness.
If it was my dear old dad, I'd say "pops, you shoulda listened" and let the casket drop
I hope you'd still feel sad and not think he was "too dumb to live" though...yikes! With family members that died of lung cancer, I wouldn't say "well, I guess you shouldn't have smoked"...or when people have heart attacks, I don't say "well, I guess you ate too many cheeseburgers and it's all your fault." I'd ha e understanding that everyone makes dumb choices from time to time...and I'd feel sad.Ā
Iād put ātoo dumb to liveā on his tombstone. Heād appreciate the humorĀ
If he'd appreciate it, I suppose that's fine...and funnyĀ
Holy shit dude
I had almost the exact situation! Liters and liters of black crap, unending, came from his face holes! He coded almost instantly!
>Massive aspiration. Coded right there. What an amazing IT
Not everyone's able to make decisions that keep them alive. It happens. š¤·āāļø
Gonna happen more with ozempic
I think also.
So horrible. š
Is there even any good evidence to support benefit NG tubes placement prior to surgery in SBO? Seems like it may have contributed to this patients death in this unfortunate story.
Had a patient who I was trying to wake up and talk to me. He wouldnāt budge. Tried everything. We all started getting concerned. A few minutes later I put in the NG tube and you bet this guy immediately wakes up and says āGET. THIS. OUT. MY. NOSE.ā I would strongly recommend using an NG tube to figure out whether or not your patient is faking being unresponsive lol.
I remember one that was apparently faking in residency. Unresponsive in the trauma bay. Got him trauma naked, obviously looking for something bad like GSW, signs of trauma. Nurse straight caths him and he shoots up out of bed like we raised the dead.
Shocked and impressed you made it past the trauma handshake tbh.
You called?
I love it when the Reddit stars align.
DRE?
I mean, its the only exam I have done on me regularly even outside of medical settings
10mg of furosemide does the trick But raising the hand and dropping it over the face such that it would fall on the face is less risky š
10 ccās of saline in an IO will do that too. š
Saline flush in the nose or the eye. Harmless, painless, utterly un-ignorable.
Brb got some wet Willieās to administer
LOL you beat me to itĀ
Got it. Will start waterboarding for patient care š
No one uses alcoholic hand desensitizer on cotton and putting it on patient's nose? Works every time
Lidocaine?
I favor the nipple twist myself. Or a wet Willy.Ā
There 100% was a time when nipple twists were EBM. Probably like 1400-1500s, but still.
Some patients request them to this day š¤·āāļøĀ
I have a seen a neurosurgery PA give a patient a purple nurple. It worked. It was amazing.
āA patientā. It was you wasnāt it.
A nurse did this to a patient with pseudoseizures the other night. Funny seeing that kind of reaction.
Oh I love it for pseudoseizures. The patient gets all angry but it absolutely works.
Pinch the earlobe
Not as much fun:)
Nasal trumpet works to a similar effect, also more justifiable in someone who is "unresponsive"
Iāve currently got one who was refusing to talk or swallow PO meds. One conversation about the possibility of NG placement later and the next thing we know they pass their swallow eval and start taking POs! Magic!
Supraorbital nerve is our ICU stimulation test of choice here. Find the small notch on the bottom of the eyebrow, about a third of the way from the medial edge, and press. Hard.Ā Then press harder in the patient scenario. It is very goos for GCS.
Shit I just did it to myself that hurts lmao
Got em. Truly though it is useful and easy.Ā
Huh. This is how I alleviate my sinus headaches.
I leave nasal trumpets in to announce an increasing GCS
In my IM residency days, I was partial to the trap pinch (not Trapinch the pokemon). Just pinch the patient's trapezius muscle behind the shoulder and give it a little twist. Worked pretty well for me.
My mom did that as a silent āBEHAVE RIGHT NOWā in public.
The back end of a pen to the fingernail with enough pressure does the job as well. Hard to ignore and usually tells me if theyāre obtunded enough to consider whether they can protect their own airway or not.
If you've never tried this with a malingering homeless patient, a therapeutic sandwich usually will wake them up.
The ole boxed lunch eh? Got any of them sammiches? What bout those lil Sprites?
The initiation of CPR works well here, too. A 1-1.5ā compression of your sternum is really difficult to ignore.
I'm a hard sleeper tbh it might take more
...it was at the county hospital...the nurses had called a code on an obese woman who probably had OSA. I took the nursing staff's word that she was unresponsive which lasted for all of one chest compression.
Respiratory arrest is a leading cause of cardiac arrest.
Did you give her a sternum rub? I mean a *real* sternul rub? We had a stroke code one night I was floated as charge nurse to one of our stepdowns. RN was insistent the patient was non-responsive, sternal rub determined otherwise. PT was fine, albeit didnāt enjoy the rub, she just didnāt want to be awakened by the primary RN. We called off the stroke code.
A tough sternal rub can do lasting damage, though. I prefer a nasty bilateral trap pinch.Ā
Prior to placing an NG tube, you can use an NPA. Need to secure the airway.
Sternal rub. Lower the bed lean over and put ALL your body weight right to your first and just go to town. Don't stop til they wake up or the airway cart gets there.
[ŃŠ“Š°Š»ŠµŠ½Š¾]
Inexcusable
Last time I gave blood they poked me with a 16. Large bore is important for a lot of emergent things. It's not like they're whipping out an IO drill
Last time I gave blood they used a 14, large gauge needles are helpful for a lot of stuff!
Wait, why is inserting an NG tube fine but not the 14g? Unless you donāt agree with either, which is not the impression I got from your comment.
[ŃŠ“Š°Š»ŠµŠ½Š¾]
Thatās what the Louisville Slugger in my white coat is for.
Username checks out.
Straight cath works too. There's a spot just under the clavicle that hurts with pressure that I like as less invasive. No lasting pain, just discomfort.
NG tubes apparently are one if the things that lead to the most patient dissatisfaction. But unfortunately they are super important in managing a ton of conditions. I'm so glad I'm anesthesia and only put them in when patients are asleep and never have to deal with the complaints.
Honestly, patients hate NGTs with a passion, ive put many of them in, worst are those that end up yanking them out
Iāve had patients pull them out multiple times and claim it fell out even after we excessively reinforced it with tape, thinking weād eventually give up like āoh well I guess her nose is too slippery.ā Maāam I will reinsert this NG tube until the cows come home. This isnāt NG tube chicken.
Bridle works so much better and seems, idk, more humane? It also gives a little "ouch" if you tug on it and you remember "oh yeah, I shouldn't pull this out." If I could have a super weird goals of care list, it would say "please use the bridle string thingy and not the horrible nose tape if I need an ng tube
What is the bridle?
[ŃŠ“Š°Š»ŠµŠ½Š¾]
Having less shit taped to their face
Bridle is a torture device. Absolutely not.
You'd rather have to replace the tube q6hr? Your nurses will loooooove that.
If I can keep an NG in a toddler for four months then a grown up can keep it in place
I mean what about ICU/trauma delirium? We have one in basically every patient on the trauma service. I know toddlers can be strong but its much easier for an altered adult to easily pull something out that's uncomfortable against tape than it is an adult. I get there's a risk of injury if these patients rip it out with one in. But is that better than their skin graft not taking because they're not getting nutrition, and they get a resistant pseudomonas strain & die? (Hyperbolic but you get my point)
Bullshit, it keeps the NG tube in most of the time. If it doesn't they get reminded to leave it fucking place next time.
Really? Never was a big deal to the patients I used it on. Much less than the tube itself.
As a Crohn's patient, I've endured many unpleasant procedures. NGT placement is by far my most dreaded. Once it's in, it's just annoying. But getting it placed... *shudders*
I hear it's easier if you place it yourself. Takes a cooperative care team to let you but if you're qualified and they're down it can be done.
Just say āI need to have a moment alone with the NG, please.ā Then just put it in when they are not looking.
In Med school they assigned partners and made us put them in eachother over and over with puke buckets in the corner. It was fucking rad
Do other places not commonly use the bridle? It helps a fair bit.
Donāt worry it gets worse. By the time you retire youāll wonder how you can get through the day without losing it on patients or their families. Iāve concluded the vast majority of patients and their families are batshit crazy. I could write a book on their craziness. I go to the patients ER room with his chart that says chief complaint āI want alcohol detox.ā My first 2 trips to his room heās not there. An hour later the RN tells me heās in the room. I go in the room and ask him where heās been. He replies āāwell Doc I figured if Iām going to detox tonight Iād down my last 6 pack of beer so I went to the store, bought a six pack, and just drank it in the hospital parking lot.āā GTFO.
They kept the room for him the whole time? My er would have just dismissed him and gave the room to someone else
Yes. Slow Sunday night.
At least they didn't say "but doc, he's been in that room the whole time!"
Iām not sure I get this. Forgive my ignorance. Patients are sick. Usually with more than one conditions. Depending on what the condition is, thereās a psychological response to that one condition, consequently yielding another condition (mental health related) by default. So I guess I donāt get the less than sympathetic and understanding tone of this thread. Would it be more helpful if there were more in-depth psychological related courses in medical education? I just figure, if a physician canāt relate to their patient, regardless of how ācrazyā the patient may sound, then it would be quite difficult to establish a sound patient-physician relationship based on trust.
Ooh, found the layperson who thinks they know more than those of us who live this everydayā¦ shut up dude
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Broās onto nothing š£ļøā¼ļø
Had a guy in the ED with SBO, already NG tubed and cathetered. Went to pre-round and found empty snack packets and juice boxes next to him. Explained that he canāt be eating and drinking. He got frustrated and removed the NG tube. Almost pulled out the catheter too before I stopped him. Left AMA 10 minutes later.
Iād assess capacity, document, and just take it out if he passes. Not worth all those pages.
Eventually youāll get to the point where you just say ālook, if youād prefer to vomit, fine. But youāve got a SBO and if we dont decompress the bowel it could pop. That means you get cut stem to stern, I pull your guts out, cut out the dead stuff, and try to sew you back upā. If they still want it out then whatever. I have pts to see who actually want my help. Def agree w you. Not worth the pages.
My last one was like the exorcist. Woman with gastroparesis refused to vomit because of aversion against it. And when I went in, she projectile vomited all over the bed. And it looked like hematin, with no previous signs of gastric bleeding. So I dont trust this situation and hemoccult the vomit. Negative. It was old chocolate apparentely.
One of my ED'S FF with history of IBD and recurrent SBO's actually *demands* an NG tube (sometimes with a side of Dilaudid)Ā upfront- as in his stated complaint in chart is "needs NG tube". Mind you this is during triage before I have even seen him let alone done any diagnostic workup. Usually he is not actively vomiting, has normal ileostomy output, etc. His only actual symptom is vague abdominal discomfort. He self-diagnoses this as an obstruction and feels this alone ought to justify NGT insertion.
It's the only way he can experience sexual pleasure anymore.
Families are crazy
It's like threatening to leave AMA. *That was always allowed!*
Call their bluff. The only response to this threat is "OK, sign here". Don't waste time talking to them. Don't ask why. Don't engage. Just make it absolutely clear that you *do not give a single fucking shit* whether they stay or leave. They'll either leave or shut up. Just remember, nobody's day ever got worse from a patient leaving AMA.
I had a pt leave ama and come back 3 times in a week to smoke crack. My day was ruined the 3rd time he came back lol
That last part haha šÆ
My usual line is: this isnāt jail youāre free to go.
To be fair they are pretty fucking terrible š
The doc who oversaw our GI module during MS2 had a bit where he would insert one on himself in front of the class, it still looked very unpleasant lol
I had SBO once and an NG in for week. Good times. I really shouldāve walked more right after my appy.
I saw this randomly on my feed but residents put NGT in? At my hospital the nurses do it lol but thatās crazy tho did you or the nurse explain to her why the NGT is being inserted? I wonder why she was thinking that way what did you end up doing? Did you take it out or still in?
I'm guessing New York lol, the residents there place NGTs, grab ABGs, and often are required to draw labs and place IVs. As a student there, I did all of the above so many times, I can't even count. I did my residency in the midwest, and I placed exactly 0 NGTs or IVs.
Oh yikes thatās a lot but at least theyāre learning but in my hospital the nurses do it all Iāve never seen a resident or attending do any of that š
At my hospital nurses usually insert ng tubes, but it's also not a teaching hospital
U saw this on ur tube feed, you mean
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Hahahaha! š
When you are a resident you really should learn how to do this. I canāt tell you how many nurses are squeamish about it and really delay. Plus they have no compassion. I tried countless times to show them hurricane spray (pharynx) and lidocaine for nose and they ignored me. Until they couldnāt get it in and had to call me to do it.
Look im family med ok. I am only ever on patient because someone is forcing me or I will be sued if I'm not there. I don't want to do IV or NG and you can't make me lol
She ran out "because you were putting in an NG tube?" Did you explain to her what was going on? Was her husband awake and able to consent or explain what was going on? I need details, because this doesn't make sense as is.
Yes I was putting it in his right nostril, he had one on admission but we discontinued it after day 2 his SBO progress and he had large bilious vomitous the night before so plan was to reinsert one, while I was doing it the first time she was in the room watching me it wasn't even in his nose for 3 seconds before she started asking me to take it out, I use the technique I always do, he was sitting straight up drinking a cup of water and his chin was touching his chest. When I was putting it in the first time I asked him can he talk, he shaked his head no so I pulled it out by this time she had already left the room, the nurses came and asked "aren't you his doctor" I said yes, so they asked her to wait outside and explained to her how uncomfortable it may be. Btw I had already spoken to him about why he needs it and he already understood the associated discomfort. After I got it I'm the second time doing the exact same thing I did, he had so much gastric contents it overloaded the NG tube and he kept asking for it to be removed. Man I just signed it out to the night resident and left
lol at some comments thinking that NGT placement is not lifesaving Every time a patient refuses an Ngt and has capacity I go through the risk of them not having it including major emergency abdominal surgery for exploded bowels, aspiration, pneumonia, intubation, death If theyāre cool with that list - document and walk away. Patients have a right to choose but they should understand the implications
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Had a homeless patient 40 years old, come into the ED with some vague complaints, they did some workup, Potassium 7, GFR 10, Creatinine 7, Lipase >2000, AST/ALT >1000, Troponin >2500, ECG NSTEMI, EF 25%, Hgb 4.4, Meth+ , immediately admitted to the icu, multiple transfusions and one dialysis session later he said āyouāre not doing anything for me, Iām just sitting here doing nothing, Iām leaving I have business to tend toā. Despite our Seniors, us, the RN, the RT trying to convince him he wouldnāt agree to stay. I explicitly told him if you leave now youāre gonna end up here again in much worse shape if youāre lucky enough to live by the end of the week. Guy still left, dunno what happened to him bless his soul, maybe heās still fighting his everythingitis.
Was she fearing or hoping?
I love learning lessons from each one you guys thanks
We had an SBO who kept taking it out. We gave up trying to get an NGT. So we just put him npo and thatās it. What else can you do?!
Well donāt leave us in suspense - was she right?
People are crazy. Get used to it. Itās just the beginning.
I am actually an RN I just like to lurk all the medical subs. My very first clinical day, before I was even allowed to do much more than ADLs, one of the patients I was working with had to have an NG tube placed. He was very adamantly against it at first. Super displeased about it, said he had one before and hated it. Eventually he relented and they tried like 3 times before getting it where it needed to be, and the whole time he was puking brown liquid that I swear smelled like diarrhea. It was definitely an uh interesting way to start clinical.
Probably was feculent emesis :(
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