Sunday, May 15, 2011

A Near Miss ‘Never Event’: A Truly Futile PEG Tube

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I barely escaped from an embarrassing situation recently in the hospital. I was consulted to place a feeding tube, called a PEG, in an ICU patient. We gastroenterologists are rarely consulted for our opinion on whether these tubes make sense, which they often don’t. We are recruited to these patients simply to perform the technical function of inserting the tubes, so that Granny, or Great-Granny, or Great-Great… , won’t starve. Multiple medical studies have demonstrated that providing this nutrition to individuals with advanced dementia doesn’t benefit them. In addition, while it may seem intuitive that artificial feeding provides comfort, this may not be the case. It may provide more comfort to the physicians and family than it does to the patient.

The above paragraph is not a rigid presentation. Obviously, the decision to place and accept a feeding tube must be individualized. Regardless, it is inarguable that too many of these tubes are being placed for the wrong reasons.

An ICU nurse contacted me to place a feeding tube in one of her patients. There was a large group of visitors hovering around the bedside. As is every physician’s custom, I asked the nurse to summarize the patient’s hospital course and the active medical issues. The consulting physician had requested a PEG feeding tube and a tracheostomy tube. This latter tube is inserted surgically into the windpipe and is connected to a ventilator. (Patients who cannot be weaned off of respirators often have these ‘trach’ tubes inserted as the original breathing tubes cannot remain in the throat beyond a few weeks.) I asked how long the patient had been on a ventilator, and she replied that she was breathing on her own. Even a concrete thinking gastroenterologist thought it was odd to place a ‘trach’ tube in a patient whose own lungs apparently were functioning adequately. This would be analogous to placing a PEG tube in a patient who had just supersized his fast food order.

While this scenario never achieved ‘never event’ status, it does illustrates how medical mistakes can happen. The consulting physician confused two of his patients. The patient assigned to me needed neither a PEG nor a trach, but one of her neighbors did. I was relieved that I didn’t enter the patient’s room to discuss the pros and cons of feeding tubes to the large group assembled there. What if I did enter the room and there were no visitors? What if the patient was demented and wasn’t eating well? One can imagine how a ‘never event’ can happen, especially if necessary safeguards and checks are bypassed or ignored.

I have already expressed in a prior post about why unnecessary PEG tubes are placed. I left one reason off the list. Luckily, it didn’t happen in this case.

2 comments:

A. Bailey said...

It wasn't a close call. We may be asked to do technical stuff but we're still not relieved of our responsibility to perform an H&P, although Medicare might not have paid you for it.

There are questions that never seem to be asked in these situations. What was going on in the nurse's mind? Did she have too many patients because of staffing problems? Was she exhausted from working a long arduous shift? Was she preoccupied because her husband filed for divorce or her son just got it with a possessions charge? Did she have so much seniority that she just doesn't give a rip anymore?

I doubt the last one, as the ICU isn't typically a good place to ride out one's career.

Non-medical folks and some harsh critical medical types would just assume she was an evil incompetent person. Odds are she's not.

Michael Kirsch, M.D. said...

Thanks for the comment, AB. The attending goofed and the nurse didn't question an order that made no sense. Thus, begins a cascade that can lead into the Canyon of Never Events.

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