LIN Session – In Flight Emergencies

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Nurses Edition Commentary

Mizuho Spangler, DO, Lisa Chavez, RN, and Kathy Garvin, RN

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Chesney F. -

Michelle, always appreciate your tips & tricks about EM practice in the real world (Sharpies, a woman after my own heart.) In the future, would you comment about how to minimize the distress of NG tube placement? I've tried nebulized lidocaine, but it hasn't had to desired effect. Maybe our timing of nebulizer to NG tube placement is sub-optimal.

Michelle Lin, MD -

Good questions about NGT placement. I haven't found the perfect approach. Nebulized lidocaine's effects are rather short-lived so as soon as it's finished, I tend to place within 1-3 minutes. In addition I use the urojet lidocaine vial to place 2% lido down the nares until they swallow a little bit.

Of course, I challenge that we may be placing NG's too often unnecessarily for patients who report hematemesis. What they need usually is a more definitely EGD rather than NG tube and lavage.

Anyone else with tricks?

Bill Hinckley, MD -

The NGT plastic has memory-- use it to your advantage. Once the pt is prepped w/ oxymetazoline + lido, before beginning to place the tube, curl it tightly around 2 or 3 of your fingers to get a nice curved shape memorized in the plastic. Use that curve to "turn the corner" at the back of the nasopharynx. Once you feel the tube turn that corner (and you should be able to feel this definitively), twist the tube 180 degrees so that now the curve you created in the plastic has the tip of the tube pointing posteriorly, so that it's almost guaranteed to go esophageal (as opposed to inadvertently tracheal) as you continue to advance the tube.

Patrick M. -

Here is exactly what I have been doing for the past two years and it works remarkably well - I have showed this to the nurses and their success has skyrocketed as well -

In short - great success using the viscous lido - just plug one nostril and have them inhale/snort until it hits the back of the throat and they can taste/cough it.

For placing the tube in the side channel of an OP airway and sticking it in an ice water slurry to have it retain its shape has been the best technique in getting successful placement when other methods failed and is always my first line go-to.

Jennifer M. -

I have never traveled with a copy of my physician license. When you copy them on a copier, they come up null/void as I guess the blue backing is a not to be copied. I would assume if the copy said null/void, it would not be accepted. Would your physician id from the hospital work? ACEP membership card? Or what is recommended to carry on the plane. I would hate to have someone hurt and not be able to help because I didn't carry the right documentation. Thanks.

Lindsay M. -

In my state (Michigan), any state-issued professional license comes with two pieces of paper: a big one you can pin to your office wall, and a smaller "wallet card" version you can have laminated . Most physicians and nurses I know, myself included, carry the wallet card. In a pinch, I'd imagine anything would do: hospital badge, ACEP or ENA membership card, ACLS provider card, whatever you have. (They may not even ask you to produce any physical documentation. In both of the in-flight emergencies I've responded to, the flight crew only took down my name, address and phone number. I offered my RN license, hospital badge and some other cert cards I had, and they said "That's fine, we only needed your address." Perhaps they do a license lookup? They have to have your personal details for the TSA screening, after all...)

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