[WHISTLING]

- GIRLS, HUH?

YEAH, SAD, HUH?

I TRY TO PRACTICE,
BUT I CAN'T DO IT.

I JUST SHAKE MY HUSBAND AND SAY,
"WHISTLE FOR ME, WHISTLE."

COS HE'S GOOD AT IT.

ALRIGHT, WE'RE MOVING ON.
NEW MODULE.

GREAT JOB ON WOUND CARE.

IT'S STILL BETTER, YOU KNOW,
THAT YOU'VE GOT A LITTLE
WOUND CARE.

HOLD IT FOR THINKING A
LITTLE MORE TACTILE.

HOLD IT, WHAT DID I SAY,
THINKING, I DON'T KNOW
WHAT I SAID.

IT'S JUST A DIFFERENT
CONCEPT AWAY FROM IV'S,

KIND OF, A MORE HANDS-ON
AND SO FORTH.

WHO TOLD ME THEIR GOOD STORY,
ARE THEY IN HERE?

NO, SOMEONE WHO WAS DOING
A WOUND THIS WEEK WITH
THE WOUND THERAPIST.

AND IT WAS BIG AND DEEP AND
I BELIEVE SHE HAD 2 OR 3
ON HER BODY.

AND SHE'D STAND AT HOME
WITH ACTUALLY --

AND, KIND OF, GOES, "WHAT'S THAT
WHITE STUFF ALONG THE EDGE?"

AND THE GUY WAS, "I DON'T KNOW."

AND SO THEY GOT A
LITTLE APPLICATOR AND
SHE STARTED PROBING IT,

SCOOPING AROUND AND SOMEONE
HAD LEFT A 2X2 IN THE WOUND

AND THE SKIN HAD COVERED
TO THE EDGE OF IT

AND SO THEY HAD TO,
KIND OF, DIG IT OUT.

SAID IT SMELT SO FOUL WHEN THEY
GOT IT OUT OF THE WOUND.

AND THE GAL JUST LOOKED UP
AT HERE AND SAID,

"WELL, HERE'S A GOOD LESSON
FOR YOU."

NEVER USE A 2X2 OR PACK
A WOUND WITH A 2X2.

SO IT WAS A 2X2, NOT A 4X4,
SO SOMETHING REALLY TINY DOWN
DEEP INTO A CREVICE.

AND, [INDISTINCT],
"I'LL NEVER USE A 2X2."

AND SHE SAID IT WAS
SO FOUL AND SO AWFUL.

THE OTHER THING I WOULD JUST
MENTION ALONG WITH THAT IS THAT
WHEN PEOPLE PACK A WOUND,

THEY NEED TO NOTE WHAT THEY
PACKED WITH OR TELL
THE PERSON BEFORE

SO THAT THEY KNOW WHAT
THEY'RE LOOKING FOR.

I MEAN, EVEN IN SURGERY THEY
COUNT THEM UP, YOU KNOW,

TO MAKE SURE WHAT THEY PUT IN,
THEY TOOK OUT.

AND IF YOU'RE DOING SOMEONE
ELSE'S DRESSING, YOU NEED
TO KNOW

WHAT WENT BEFORE YOU TO KNOW
WHAT TO GET OUT OF THERE.

SO ANYWAYS, THANK HEAVENS FOR A
GOOD STUDENT WHO WAS CURIOUS

AT ASKING BECAUSE THE OTHER GUY
WOULDN'T EVEN HAVE PROBED
IT EITHER,

BECAUSE SHE WASN'T LOOKING FOR
IT. YOU KNOW WHAT I MEAN?

SO, ANYWAYS,
I LOVE YOUR STORIES,

I LOVE STORIES, HELPS ME
PUT IT ALL IN PERSPECTIVE.

OKAY, WERE MOVING ON, WE'RE
MOVING TO NASOGASTRIC INSERTION.

AND WE'RE GOING
TO INSERT 2 TUBES.

WE'RE GOING TO INSERT A
NASOGASTRIC TUBE INTO AN ADULT,

AND WE'RE GOING TO DO A FEEDING
TUBE, AN ORAL GASTRIC
TUBE INTO A BABY.

SO, IT ACTUALLY DOES NOT TAKE
LONG. IT'S ANOTHER FAST DAY.

WE TRY TO GIVE YOU 2, KIND
OF, NICE BACK TO BACKERS

HERE WITH ALL THE TESTING
WE'RE DOING.

SO, BE PREPARED TO BE
IN AND OUT IN 20 TO --

NO MORE THAN 30 MINUTES, IT'S
FAST. WE'LL BE WAY AHEAD
BY THE END OF THE DAY.

SO COME EARLY,
SO WE CAN GET GOING.

ALRIGHT. BEFORE WE GET GOING,
JUST A LITTLE INFORMATION
THAT YOU NEED

TO APPRECIATE WHAT YOU'RE DOING.

WE'RE GOING TO PUT A TUBE INTO
A CLIENT THROUGH THEIR NARIES

BACK DOWN THROUGH THE
NASAL PHARYNX AREA.

THIS IS THE NARIES THROUGH
THE NASAL PHARYNX.

AND THEN WE HAVE A LITTLE
SPLIT-OFF THAT HAPPENS HERE

OF ESOPHAGUS DOWN TO
STOMACH OR TRACHEA.

THE GOAL IS TO STAY IN ESOPHAGUS
AND INTO STOMACH,

NOT HAVING A LITTLE DETOUR
INTO TRACHEA.

SO I'LL TEACH YOU A COUPLE
OF TECHNIQUES OF WHAT TO DO.

WHEN WE DID OUR FEEDING TUBES
FIRST SEMESTER, RIGHT,
WE HAD TUBES IN

AND WE DID FEEDINGS,
THEY WERE NASOGASTRIC TUBES.

IT WAS A TUBE SIMILAR TO
THIS THAT GOT PUT IN
THROUGH THE NOSE,

DOWN, DOWN, DOWN INTO THE
STOMACH, AND WE FED.

NASOGASTRIC TUBES NEED TO
BE IN FOR LESS THAN 2 WEEKS.

THEY'RE A SHORT-TERM AND
ACUTE CARE INTERVENTION.

TYPICALLY AS THE NASOGASTRIC
TUBES IS IN FOR 2 WEEKS
FOR FEEDING,

IT'S BECAUSE THEY HAVE AN ACUTE
PROBLEM AND OR THEY'RE PLANNING

TO GET TO A FEEDING TUBE OR
A GASTROSTOMY TUBE,
A STOMACH TUBE.

THESE ARE NOT GOOD FOR
LONG-TERM BECAUSE THEY CAN GET
INADVERTENTLY PULLED OUT

AND THERE'S A RISK FOR
ASPIRATION.

AND BECAUSE THEY'RE SO LARGE
THAT THEY CAN TRAUMATIZE

THE TISSUE AND THEY CAN
CAUSE SKIN BREAKDOWN AND SOME
ULCERATION IN THE NARIES AREA.

AND THAT'S NOT GOOD EITHER.

SO YOU CAN'T JUST LEAVE
SOMETHING FOREIGN IN A
BODY PART FOR A LONG TIME

WITHOUT THERE BEING SOME KIND OF
SIDE EFFECT TO THAT.

SO YOU WANT TO BE THINKING
WHAT SIZE IS THAT?

SO, FOR --

LET ME JUST EXPLAIN THE TUBES.
THIS IS CALLED A LEVINE TUBE.

THERE IS NOTHING SPECIAL
ABOUT IT OTHER THAN IT'S
A STRAIGHT TUBE.

IT HAS A RADIOPAQUE LINE IN IT
SO THAT WE CAN CHECK
WITH X-RAY

FOR PLACEMENT
WHICH IS REALLY KEY.

AND IT'S USED PRIMARILY
FOR FEEDING,

NOT USUALLY FOR TAKING THINGS
OUT OF THE STOMACH.

SO, A FEEDING TUBE, OFTEN
CALLED A GAVAGE TUBE.

FEEDING, PUTTING SOMETHING
INTO THE STOMACH.

BECAUSE THOSE ARE TRAUMATIC FOR
SOMEONE THAT MIGHT NEED IT
FOR A LONG TIME,

THEY HAVE, WHAT'S CALLED A
DOBHOFF TUBE OR A FEEDING TUBE.

AND I'LL PASS THIS AROUND SO
THAT YOU CAN SEE IT. MINE'S
GETTING A LITTLE MANGLED.

BUT THE TUBE IS A
SOFT WHITE PLASTIC,

VERY SOFT AND MUCH EASIER ON THE
NARIES, AND THE PASSAGEWAYS.

IF SOMEONE NEEDS TO HAVE
IT A LITTLE LONGER,

THEY DON'T WANT TO HAVE
THE SURGICAL PROCEDURE,

THAT PUNCTURE FOR THE
GASTROSTOMY TUBE.

TO PUT THIS TUBE IN, THERE'S
A GUIDE WIRE ON THE INSIDE

SO YOU -- AND A WEIGHT
AT THE BOTTOM,

BECAUSE THEY WANT THIS TO, KIND
OF, MIGRATE DOWN INTO
THE INTESTINES.

SO YOU PUT IT IN THE SAME WAY,
I'M GOING TO TEACH YOU IN A BIT.

AND THEN...

..AT THE END HERE,
ONCE IT'S IN PLACE --

[PHONE RINGING]

OH, YOU'RE QUICK.
THOUGH, THAT'S GOOD.

- THERE'S [INDISTINCT]
IN MY WAY.

- OH, MY HANDS ARE JUST
MESSED UP RIGHT HERE.

YOU DISCONNECT THE PIECE,
AND MINE IS SO OLD.

AND THEN YOU PULL THE
GUIDE WIRE OUT. DON'T
PULL IT ALL THE WAY UP.

YOU CAN SEE THAT YOU
TAKE THE WIRE OUT AND

WHAT GETS LEFT BEHIND IS
THE SOFT, SOFT PLASTIC.

SO YOU DON'T GET THE PRESSURE
THAT THIS HARD LEVINE TUBE
PUTS ON THE NARIES.

SO YOU CAN USE THESE FOR A
LITTLE BIT LONGER.

THESE ARE UNACCEPTABLE TUBES FOR
PUTTING IN FOR SOMEONE THAT
HAS, FOR EXAMPLE,

A GI BLEED, GASTROINTESTINAL
BLEEDING AND ULCERATION,

AND YOU'RE PUTTING A TUBE
IN TO SUCTION OUT THINGS.

BECAUSE IT'S TOO THIN,
AND IT WILL CLOT OFF.

AND SO, IT'S ONLY FOR FEEDING,
ONLY FOR PUTTING THINGS IN,

ONLY FOR A LONGER-TERM
FEED SITUATION.

DOBHOFF, SOFT...

..WEIGHTED, GOES DOWN TO THE
INTESTINE AND I'LL PASS
THAT AROUND.

IF YOU HAVE A FEEDING TUBE
OR WHICH IS A DOBHOFF

OR A LEVINE TUBE FOR FEEDING,
THEY'RE GAVAGING.

WE PUT TUBES IN FOR OTHER
REASONS, THOUGH.

I ALLUDED TO A GI BLEED, WE
NEED TO GET SOMETHING
OUT OF THE STOMACH.

THEY MAY TAKE TOO MANY PILLS,
SUICIDE ATTEMPT OR JUST
A MISTAKE, A CHILD.

AND SO WE LAVAGE THE STOMACH.

WE PUT A TUBE DOWN INTO THE
STOMACH AND THEN WE
INSTILL FLUIDS,

NORMAL SALINE AND PULL OFF
THE STOMACH CONTENTS

TO GET WHAT'S IN THE STOMACH
OUT OF THE STOMACH.

AND THAT'S CALLED LAVAGING.

OR, I THINK IN SPANISH, I THINK
IT'S LA WASHING, IT'S A WASHING,

IT'S A CLEANING, LAVAGE.

WE ALSO PUT THE TUBE IN
FOR A THIRD REASON,

VERY SIMILAR TO LAVAGING, WE'RE
TRYING TO GET SOMETHING OUT.

BUT WE'RE TRYING TO HELP
THE INTESTINES AND IT'S
CALLED DECOMPRESSION.

SOMETIMES, THERE'S A
BLOCKAGE IN THE BOWEL

FOR WHATEVER REASON,
CANCER, STOOL, SURGERY

AND THE INTESTINES AREN'T MOVING
ALONG LIKE THEY SHOULD.

AND IF THINGS GET, KIND
OF, BOUND UP IN THERE,

THE CLIENT GETS VERY DISTENDED,
THEY GET BLOCKED UP

AND THEY MAY HAVE
NAUSEA AND VOMITING,

AND THE STOMACH NEEDS A REST.

THE STOMACH IS STILL GOING
TO PRODUCE JUICES, RIGHT.

EVEN THINKING ABOUT A
DOUGHNUT, CHOCOLATE, PIE,

YOU SALIVATE AND IT STARTS
RUNNING AND YOUR SYSTEM
CREATES JUICES.

AND WE NEED TO KEEP THOSE
JUICES FROM GOING DOWN
INTO THE INTESTINES

BECAUSE THE CLIENT CAN'T
MOVE THOSE ALONG.

SO WE'LL PUT A TUBE DOWN
FOR DECOMPRESSION.

I NEED YOU TO APPRECIATE ALL OF
THAT BECAUSE YOU NEED TO KNOW
WHY YOUR CLIENT NEEDS THE TUBE

SO THAT YOU CAN PICK THE RIGHT
TUBE AND THE RIGHT SIZE TUBE.

IF YOU'RE JUST GOING TO PUT
A TUBE IN FOR FEEDING,

LEVINE IS APPROPRIATE.

BUT IF YOU'RE GOING TO
BE PUTTING YOUR CLIENT --

A TUBE DOWN YOUR CLIENT,

AND YOU'RE GOING TO BE
SUCKING CONTENTS OUT

FOR A LONG TIME TO GIVE
THE STOMACH A REST
FOR DECOMPRESSION,

WE USE WHAT'S CALLED
A SALEM SUMP TUBE.

IT'S A TUBE THAT LOOKS VERY
MUCH LIKE THE LEVINE TUBE,
IT'S STILL A TUBE.

BUT WHAT COMES OFF OF IT IS
AN AIR VENT OR THE SUMP,
IF YOU WILL.

AND WHAT THIS DOES IS THAT
THERE'S ANOTHER LUMEN
IN THE TUBE

AND IT ALLOWS AIR TO
VENT OUT OF THE TUBE

SO THAT THE TUBE DOESN'T ADHERE
TO THE STOMACH LINING.

WHEN WE HOOK THIS PIECE
UP TO SUCTION,

IT WILL -- IT CAN STICK
AND SUCK ON TO TISSUE

AND CAUSE FURTHER DAMAGE AND
WE DON'T WANT THAT TO HAPPEN.

SO THE LEVINE PIECE ALLOWS
FOR AIR TO ESCAPE

SO THAT YOU DON'T GET SUCTION
AND TEARING OF THE MUCOSA
OF THE STOMACH.

ALL OF THAT IS DESCRIBED
VERY EXCELLENTLY

IN THE FIRST COUPLE
OF PARAGRAPHS

OF YOUR OCHEM BOOK
OF NASOGASTRIC TUBES.

AND IT'S GOING TO DISCUSS ABOUT
THE USE FOR DECOMPRESSION

FOR FEEDING AND
FOR REMOVING FLUIDS.

I DON'T KNOW -- I CAN'T REMEMBER
THEM USING THE WORDS LAVAGE
AND GAVAGE.

BUT YOU NEED TO KNOW
WHAT THOSE WORDS ARE

BECAUSE THAT'S THE MEDICAL
TERMINOLOGY FOR IT.

SO THIS TUBE WOULD
GO IN THE SAME.

BUT -- OOPS. NOT DOWN THE MOUTH,
THAT WOULD BE ORAL.

YOU KNOW WHAT, THIS ONE
WON'T FIT. UH-HUH.

PAUSE. THROUGH THE STOMACH.

THEN WHAT YOU DO IS CONNECT
IT TO THE SUCTION OR PLUG IT
DEPENDING ON WHAT THE NEED IS.

AND I'LL SHOW YOU HOW
TO DO THAT IN A MINUTE.

THE TUBES COME
IN DIFFERENT SIZES.

WE'VE TALKED ABOUT GAUGES AND
THE BIGGER THE NUMBER
ON A GAUGE...

..THE SMALLER THE NEEDLE.

BUT WE'RE NOW WORKING
WITH FRENCHES.

AND THESE COME IN A FRENCH SIZE.

AND SO THIS PARTICULAR
TUBE IS A 14 FRENCH

AND THAT WOULD BE
THE SMALLEST SIZE

THAT YOU WOULD EVER WANT TO
LAVAGE OR DECOMPRESS
SOMEONE WITH.

BECAUSE, IN LAVAGING AND
DECOMPRESSING, WE'RE
PULLING OUT STUFF.

AND WE NEED IT TO BE WIDE
ENOUGH, HAVE A THICK
ENOUGH LUMEN

THAT STUFF WILL COME OUT
WITHOUT BLOCKING IT UP.

THIS LUMEN IS A 16 AND IT'S A
LITTLE BIG FOR MY LITTLE
MANNEQUIN HERE.

AND THAT'S A PRETTY
AVERAGE SIZE.

SO 14-16 WOULD BE THE LUMEN
SIZE THAT YOU WOULD PICK

FOR YOUR AVERAGE DECOMPRESSION
BLEEDING SCENARIO.

IF THERE'S SOMETHING ELSE,

MAYBE PILLS THAT ARE LARGE OR
SOMETHING, YOU COULD GO
UP TO AN 18 OR 20,

BUT VERY RARELY DO WE --
14 AND 16, BECAUSE

REMEMBER, YOU'RE PASSING
IT THROUGH TERMINATES.

WELL, ACTUALLY NOT THE
TERMINATES, THROUGH THE NARIES.

YOU DON'T WANT TO GET IT IN THE
TERMINATES. AND IT'S A SMALLER
PASSAGE HERE.

AND YOU CAN'T GO LIKE
A FOLEY CATHETER.

WE CAN GO UP TO LARGE FRENCHES,
COS THAT'S STRETCHY ANATOMY.

BONES AREN'T STRETCHY ANATOMY,

AND SO YOU'RE LIMITED
IN SIZE HERE.

YOU DON'T WANT TO
GO LESS THAT 14,

AND USUALLY 14 TO 16
IS ACCEPTABLE

FOR YOUR SIZES OF FRENCH, OKAY,
TO PASS STUFF THROUGH.

WHEN WE HOOK SOMEONE TO SUCTION

YOU'RE PULLING OUT OF GASTRIC
CONTENTS, RIGHT.

WHAT DO YOU REMEMBER ABOUT
GASTRIC CONTENTS WHEN WE
WERE DOING FEEDINGS?

- THEY'RE ACIDIC.

- THEY'RE -- THEY HAVE
ELECTROLYTES IN THEM

AND WE WOULD REPLACE THEM TO
PROVIDE BALANCE FOR THAT CLIENT.

SO HOW DO YOU BALANCE A CLIENT
IF YOU'RE SUCKING
EVERYTHING OFF?

- IV.
- IV FLUIDS.

SO, MAYBE TPN, BUT MAYBE SOME
KIND OF A SOLUTION WITH
ELECTROLYTES ADDED TO IT.

AND MAYBE AS SIMPLE AS
POTASSIUM, MAYBE A D FIVE AND A
HALF SOLUTION WITH POTASSIUM,

SOMETHING THAT GIVES A
LITTLE BIT OF BALANCE

DEPENDING ON WHATEVER YOUR
CLIENT SCENARIO IS.

SO, WHENEVER ANYONE HAS
TO SUCTION WITH AN NG,

THEY HAVE TO HAVE IV SUPPLEMENT

BECAUSE YOU'VE GOT TO BE
BALANCING ELECTROLYTES

PLUS THEY NEED SOME NUTRITION,
SOME HYDRATION

BECAUSE WE'RE SUCKING EVERYTHING
OFF OF THE STOMACH.

THE OTHER THING TO REMEMBER
ABOUT SUCTION IS

YOU NEVER DO A CONSTANT SUCTION.

BECAUSE IF YOU DO, THEN YOU JUST
TRAUMATIZE THAT TISSUE AS WELL.

SO, IT'S CALLED
INTERMITTENT SUCTION.

AND THERE'S A DIFFERENT
APPARATUS, I DON'T HAVE
ONE IN HERE.

BUT THIS SUCTION IS CONTINUOUS
AND I'LL SHOW YOU THAT
IN A MINUTE.

YOU WANT US -- IT'S EITHER
CALLED GOMCO OR INTERMITTENT.

AND WHAT IT DOES IS IT
SUCTIONS...

..AND IT CLICKS OFF.

AND IT CLICKS OFF. AND SO YOU
HEAR THAT FUNNY OFF AND ON
SOUND GOING

THE WHOLE TIME THAT IT'S
RUNNING. BUT IT PUTS THE
ANATOMY AT REST.

SO IT'S JUST NOT SUCKING
UP DRY, IF YOU WILL.

OKAY, THAT'S OUR THEORY.

WHAT WE NEED TO DO IS APPRECIATE
THAT OUR CLIENT HAS --

WHAT SHOULD WE HAVE WRONG
WITH OUR CLIENT?

OUR CLIENT IS A GI BLEED,
LETS JUST SAY.

WE'RE GOING TO CONNECT OUR
CLIENT TO LOW SUCTION,

JUST SO THAT WE HAVE
A SCENARIO, OKAY.

WHAT WE WANT TO DO IS GET
OURSELVES ORGANIZED HERE.

AND THEN WE GO.

OKAY, THE FIRST THING
I'M GOING TO DO

IS CHECK MY DOCTOR'S ORDER,
AND SEE THAT AN NG IS ORDERED.

YOU CANNOT JUST PUT A TUBE
DOWN SOMEONE

BECAUSE YOU KNOW THEY'RE
THROWING UP, YOU KNOW THEY'RE
SICK TO THEIR STOMACH,

YOU KNOW THEY'VE GOT AN ULCER
AND YOU JUST CAN'T PUT IT DOWN.

IT'S INVASIVE
AND YOU CAN'T DO IT.

AND I FIND THAT VERY
INTERESTING, ESPECIALLY WHEN
I LOOK AT ONE OF THE ARTICLES

I'M GOING TO REFER TO HERE
IN A SECOND, AND THAT IS,

THE NEXT THING I WANT TO DO
IS MAKE SURE

THERE'S NO CONTRAINDICATIONS
FOR PUTTING THIS TUBE IN.

WE TALKED A LITTLE BIT LAST
SEMESTER ABOUT THE TUBE

THAT GOT PUT INTO THE BRAIN.

LIKE, THIS IS THE ARTICLE
ABOUT THAT, FINALLY.

AND LET ME JUST SEE WHAT
THE TITLE OF IT IS.

IT'S BEAUTIFUL AND THE
PICTURE IS THERE TOO.

I GAVE YOU WONDERFUL ARTICLES.

'INADVERTENT INTRACRANIAL
NASOGASTRIC TUBE PLACEMENT.'

IT TALKS ABOUT THE CASE.
AND THEN ON THE SECOND PAGE,

YOU CAN SEE THE TUBE COILED
UP INTO THE BRAIN.

WHAT WAS INTERESTING
ABOUT THIS CASE WAS...

..IT SHOULD NEVER HAVE BEEN DONE
BECAUSE THERE NEVER WAS
A DOCTOR'S ORDER.

WHAT -- WHATEVER POSSESSED THIS
WOMAN TO PUT THAT IN
IS JUST BEYOND ME.

I'D READ THE FIRST
OF THE ARTICLE

AND I SAT DOWN A COUPLE OF
NIGHTS AGO AND I READ
THE WHOLE THING,

JUST TO GET MYSELF CURRENT, YOU
KNOW, I READ STUFF,

AND YOU JUST GOT TO REREAD
YOUR STUFF.

AND I READ TO THE VERY END
AND I WENT, "NO WAY."

SHE DIDN'T EVEN HAVE AN ORDER,

ON TOP OF EVERYTHING
ELSE SHE DID WRONG.

OKAY. SO, THE OTHER THING
THAT THEY DISCOVERED,

AND MAYBE IT WASN'T SUCH
COMMON KNOWLEDGE,

BECAUSE THEY DIDN'T TEACH
THIS TO US IN SCHOOL,

IS THAT SOMEBODY THAT'S HAD --

THEY HAD A PITUITARY PROBLEM.
AND TO GET INTO THE PITUITARY,

THEY WENT IN THOUGH
THE SPHENOID WOUND.

AND WHENEVER YOU HAVE
THAT KIND OF SURGERY,

THAT KIND OF CLIENT CAN'T
HAVE A NASOGASTRIC TUBE

BECAUSE THERE'S A BREAK
IN THE BASE OF THE SKULL,

AND THERE'S A POSSIBILITY
FOR TUBES TO GET THROUGH.

JUST THE SAME AS IF YOU
HAVE CRANIAL SURGERIES,

NASAL MAXILLARY SURGERIES,

THOSE ARE HIGH RISK CLIENTS
AND SHOULDN'T --

OR SHOULD BE CONSIDERED AT
RISK FOR HAVING A TUBE,

AND YOU WOULD ALWAYS WANT TO
CLARIFY THAT WITH THE PHYSICIAN.

SO, WE NEED TO THEN CHECK
AND MAKE SURE OUR CLIENT

DOESN'T HAVE ANY
CONTRAINDICATIONS
BEFORE THE TUBE GETS IN,

AND FOR SURE, A DOCTOR'S ORDER.

I JUST CAN'T IMAGINE WHY
ANYONE WOULD DO THAT.

OKAY. IN ADDITION TO
NOT HAVING AN ORDER,

AND TO PUTTING THE TUBE IN,
WHEN SHE CHECKED FOR PLACEMENT,

AND YOU DON'T HAVE TO CHECK FOR
PLACEMENT, SHE DIDN'T
CHECK FOR PA.

SHE CHECKED WITH AIR BY
PUTTING 30 CC'S OF AIR

AND LISTENING FOR THE WHOOSH
IN THE STOMACH WHICH IS THE
OLDER WAY THAT WE USED TO DO IT.

PROBABLY HOW YOU'RE SEEING THEM
DO IT, SOME IN THE COMMUNITY.

AND SHE CLAIMED
THAT SHE HEARD AIR.

PROBABLY WHEN SHE PUT
THE AIR INTO THE BRAIN,

SHE CAUSED, THEY CALLED IT A
CORTAL -- PNEUMO CORTAL THORAX
OR SOMETHING.

NO, THAT'S NOT THE RIGHT WORD.
OH, WELL, LOOK IT UP.

IT'S AIR, THE PNEUMO PART IN
THE BRAIN, THE CORTAL PART.

SO AIR IN THE BRAIN CAUSED
LIKE A CLOT IN THE BRAIN
FOR STROKING.

SO THE AIR DIDN'T HELP. AND
THEN THEY DID SOME FEEDING.

ON TOP OF ALL OF IT.

- BRAIN FOOD?

- HUH? BRAIN FOOD, YEAH.

KILLED HER. SO, ANYWAYS.

IT MADE ME WONDER WHY WEREN'T
THE OTHER CHECKS MADE.

WHAT OTHER CHECK WOULD HAVE BEEN
A GOOD CLUE THAT YOU'RE IN
THE RIGHT PLACE?

MAYBE LOOK DOWN THE THROAT AND
SEE IF THE TUBE WAS BACK THERE.

BECAUSE, RIGHT, IF IT'S SUPPOSED
TO GO THROUGH THE NARIES,

THROUGH THE NASAL PHARYNX,
GAG, GAG,

AND THEN GO DOWN THE ESOPHAGUS,

YOU SHOULD SEE TUBE
IN BACK OF THROAT.

NONE OF ANY OF THAT
STUFF EXISTED

EXCEPT FOR THIS REFERRED
BREATH SOUND --

AIR SOUND THAT THEY
CLAIMED THEY HEARD.

PROBLEM. SO WE ARE GOING TO
PUT IN AN NG WITHOUT ANY
OF THAT NONSENSE.

WE'RE GOING TO DO IT RIGHT AND
MAKE SURE THAT WE'RE IN
THE RIGHT PLACE.

SO WE CHECKED OUR
ORDERS, WE KNOW IT'S
NOT CONTRAINDICATED,

WE HAVE A DIAGNOSIS. WE'RE GOING
TO GATHER UP EQUIPMENT.

SO FIRST THINGS FIRST,
I GATHERED UP...

..SUCH A TUBE. AND WE JUST
HAVE FEEDING TUBES,

SO THEY'RE ALL GOING TO BE
14 FRENCH LEVINE TUBES.

ALRIGHT. SO THEY PROBABLY DON'T
EVEN HAVE ANY BAGS
ON ANYMORE.

BUT I HAVE MY TUBE.
THIS IS A CLEAN PROCEDURE.

IT'S NOT IN ANY WAY STERILE. SO
YOU CAN HANDLE YOUR EQUIPMENT,

MAKE SURE YOUR HANDS
ARE GOOD AND WASHED
IN THE GATHERING PART.

I HAVE A CHUX THAT I'M GOING TO
PUT OVER THE CHEST OR A TOWEL

BECAUSE IN THE PROCESS
THEY MAY THROW UP.

BECAUSE OF THE GAGGING
AND SOMETIMES RETCHING.

SO HAVE SOMETHING TO
PROTECT THE CHEST.

I WANT TO HAVE SOME ICE CHIPS
OR SOME WATER AND A STRAW.

THINK ABOUT THIS, IF I'M
STUFFING SOMETHING UP THEIR
NOSE, CAN THEY DRINK?

THAT'S IN THE WAY. SO THEY NEED
SOMETHING SO THAT THEY
CAN DRINK.

OTHERWISE, IT JUST DOESN'T HELP.

SO DRINKING HELPS THE TUBE GO
DOWN. SO, WE'RE GOING
TO GET THAT.

I HAVE MY PH PAPER, I HAVE THE
SYRINGE THAT I'M GOING
TO CHECK WITH.

MAKE SURE THAT YOU HAVE
A CATHETER TIP SYRINGE

BECAUSE THAT'S ALL THAT WILL FIT
INTO THAT BOTTOM OF THE TUBING.

WHOA!

I HAVE TAPE THAT I NEED
TO GET READY.

AND YOU'RE GOING TO NEED TO
GET A COUPLE OF PIECES.

AND THIS IS HOW THEY NEED TO
LOOK. ABOUT 4 INCHES LONG.

AND THEN YOU WANT TO TAKE AND
SPLIT TO ABOUT 1 INCH.

SO LEAVE ONE INCH INTACT
AND SPLIT THIS HALF. YES.

- MY CLIENT IS A [INDISTINCT].

- INTERESTING, YOU'LL SEE A
LOT OF GADGETS OUT THERE.

AND THEY DO HAVE A TUBE,

A NASAL GASTRIC HOLDER

AND IT'S A LITTLE PIECE
OF, KIND OF, ADHESIVE HERE

THAT HAS A LITTLE RING
THAT HOLDS ON.

SO THERE'S ALL KINDS OF
LITTLE GADGETS TO HOLD.

HOW DID THEY DO IT WITH
TRANSPARENT -- WHAT WAS
ON THE TUBE?

- JUST, KIND OF, WRAPPED IT
AROUND THE TUBE, TUCKED
UNDER THE NOSE.

- HMM, INTERESTING,
WHATEVER. IF IT WORKS.

I DON'T WANT TO BE TOO
CRITICAL ON THAT ONE.

OKAY, THEN YOU HAVE ONE OTHER
PIECE TO GO ACROSS THE NOSE.

BECAUSE THE NOSE IS A T-ZONE
AREA AND IT CAN BE PRETTY OILY,

YOU MIGHT WANT TO CONSIDER
CLEANING IT AND THEN
PUTTING THAT

BARRIER FILM ON HERE, THE
NON-STAIN, BUT A LITTLE
BARRIER FILM

SO THAT THE OILS DON'T CAUSE
EVERYTHING TO SLIP RIGHT OFF.

I HAVE A STETHOSCOPE BECAUSE I
DO WANT TO LISTEN

TO THE LUNGS AND THE BOWEL
SOUNDS BEFORE I GET GOING
AND CHECK IT.

I WANT A FLASHLIGHT SO THAT
I CAN LOOK IN THE BACK
OF THE THROAT

AND SEE IF I GOT A TUBE
BACK THERE.

YOU NEED SOME KIND OF CONNECTOR
FOR YOUR SUCTION EQUIPMENT.

IF YOU'RE GOING TO CONNECT
YOUR TUBING TO SUCTION,

THEN YOU NEED THIS PIECE
THAT'S TAPED TO ON BOTH ENDS.

SO I WOULD HAVE MY TUBING AND
MY SUCTION AND HAVE A CONNECTOR

SO THAT I CAN CONNECT WHEN IT'S
TO THE CLIENT AND THEN SUCTION.

OR YOU NEED A PLUG IF IT'S
FOR A FEEDING TUBE...

..OR SOMETHING. SO, ONE OF THE
TWO THINGS YOU NEED TO GET
FOR YOUR NG.

AND I HAVE A SAFETY PIN,
SO I CAN PIN ON TO THE GOWN

WHICH MEANS THAT I NEED ONE MORE
PIECE OF TAPE. FORGOT
ABOUT THAT ONE.

YOU ALSO NEED A LUBRICANT.

WHEN WE PUT THIS DOWN, YOU NEED
A WATER SOLUBLE LUBRICANT

THAT YOU'RE GOING TO PUT ON THE
TUBE, ABOUT 2 TO 3 INCHES
OF THE TUBING.

PLEASE DON'T USE THIS
ON MY MANNEQUINS.

YOU CAN HAVE IT FOR A PROP, BUT
WHAT WE USE ON MANNEQUINS
IS SILICON SPRAY

OR A LIQUID SOAP THAT'S IN
THE LITTLE WHITE BOTTLE.

DON'T USE THIS ON HUMAN BEINGS.

IT WILL NOT BE GOOD. THIS
IS FOR HUMAN BEINGS.

THIS IS FOR MANNEQUINS.

IF WE USE THIS ON THE
MANNEQUINS, IT GETS
ALL GUMMED UP.

AND THE SECOND OR THIRD
PERSON...IT WON'T GO.

ALRIGHT. I THINK I HAVE
ITEMIZED EVERYTHING.

YOU DON'T HAVE TO ITEMIZE YOUR
SUPPLIES FOR ME, YOU'LL EITHER
HAVE THEM OR YOU WON'T.

SO THE OTHER THING I JUST DON'T
WANT TO FORGET IS THAT I WANT TO
OFFER ORAL CARE FOR MY CLIENT.

BUT I ALSO MAY WANT TO GIVE
HIM THE BASIN IF HE
NEEDS TO THROW UP.

SO IT'S, KIND OF, A DOUBLE DO,
IF I FEEL LIKE THEY'RE
GOING TO RETCH.

ALRIGHT. I HAVE ALL MY SUPPLIES,

MY HANDS, I WASHED THEM
BEFORE ALL THIS.

I'M GOING TO IDENTIFY MY CLIENT,
AND HE'S A LITTLE SCHIZOPHRENIC.

I NEEDED HIM TO BE CONRAD
CURRY THIS MORNING,

OR HE CAN BE SAM SPADE,
WHATEVER. SO, WHATEVER
YOU NEED HIM TO BE.

AND PROVIDE A PRIVACY.

ALRIGHT, MR. CURRY, I NEED TO
PUT A TUBE INTO YOUR STOMACH.

I KNOW THE DOCTOR TALKED TO
YOU ABOUT THAT, SINCE YOUR
STOMACH IS BLEEDING

AND WE NEED TO GIVE IT A REST
AND GET THOSE COFFEE GROUNDS
OFF YOUR STOMACH.

SO WHAT WE'RE GOING TO DO IS
PASS A TUBE THROUGH YOUR NOSE,

DOWN YOUR THROAT,
INTO YOUR STOMACH.

AND THE TRUTH IS, IT'S A
LITTLE UNCOMFORTABLE GOING
THROUGH YOUR NOSE,

IT'S GOING TO MAKE YOU, KIND
OF, SQUINT YOUR EYES

AND IT MAY BURN A LITTLE BIT,
IT'S WHAT CLIENTS TELLS ME.

SO, WHAT I'M GOING TO DO IS
I'M GOING TO PASS IT

THROUGH YOUR NOSE TO THE BACK
OF YOUR THROAT. IT WILL
PROBABLY MAKE YOU GAG,

AND RIGHT ABOUT THERE I'M
GOING TO STOP AND LET
YOU GET RECOMPOSED

BECAUSE IT'S JUST A LITTLE
TRAUMATIC AT THAT POINT.

AFTER YOU, KIND OF, GOT
YOUR BEARINGS,

THE NEXT THING I WANT TO DO
IS, I'M GOING TO HAVE
YOU DRINK FOR ME.

AND IF YOU CAN DRINK,
AS YOU'RE DRINKING,

I'LL PASS THE REST
OF THE TUBE DOWN.

AND WHAT THE DRINKING DOES
IS IT CLOSES OFF YOUR...

..TRACHEA. THANK YOU, I WAS JUST
HAVING A MOMENT.

CLOSES OFF YOUR TRACHEA AND
THEN IT WILL GO RIGHT DOWN THE
ESOPHAGUS INTO YOUR STOMACH.

AND THAT'LL HELP SO THAT
WE DON'T HAVE IT GO DOWN
THE WRONG SPOT FOR YOU.

ALRIGHT. YOU THINK YOU
CAN DO THAT? GREAT.

EXPLAIN TO HIM WHAT'S COMING,
EXPLAIN WHAT'S HAPPENING.

THE OTHER THING I PROBABLY
WILL HAVE YOU DO DURING THIS

IS TO TUCK YOUR CHIN
DOWN WHILE YOU'RE DRINKING,

BECAUSE THAT ALSO CLOSES
OFF THE TRACHEA

SO IT DOESN'T GO DOWN YOUR
AIRWAYS. WE DON'T WANT
IT DOWN THERE.

THEN YOU CAN'T BREATHE.
THAT WILL BE A PROBLEM.

SO WE WANT IT DOWN THE RIGHT
SPOT. OKAY.

I NEED TO DO A COUPLE OF THINGS.
I DO WANT TO ASSESS YOU.

I WANT TO LISTEN TO YOUR LUNGS.

AND YOU KNOW WHEN YOU LISTEN
TO LUNGS YOU LISTEN
TO SIDE TO SIDE...

..TOP TO BOTTOM, SIDES AND BACK.

SIDE TO SIDE, TOP TO BOTTOM,
AT LEAST 6 --

WE USUALLY DO 4 TO 6
ON THE FRONT, IT VARIES.

4 -- 6 ON THE BACK, AS IF
THERE'S A FRONT MIDDLE
AND A BOTTOM.

ALTHOUGH YOU DON'T HAVE MIDDLE
LOBES, REMEMBER THAT.

AND DON'T DOCUMENT THAT THE
MIDDLE LOBES ARE CLEAR.

HAVE YOU LOOKED AT PICTURES
OF HOW THE LOBES GO UP?

IT'S THE BASE LOBE THAT'S ALL
THE WAY THROUGH THE BACK
OF YOUR LUNGS.

AND ONLY ONE LUNG
HAS 3 LOBES.

SO, YOU GOT TO BE CAREFUL
ABOUT HOW YOU DOCUMENT THAT.

YOU CAN JUST SAY
THE MIDDLE AREA,

BUT IT'S NOT THE MIDDLE LOBE
NECESSARILY, THAT'S CLEAR.

SO, BE CAREFUL IN YOUR
DOCUMENTATION.

SO I'M LISTENING TO THE LUNGS
BECAUSE I WANT TO MAKE
SURE THE STATUS

BEFORE THE TUBE GOES IN, IN
CASE THERE'S ANY ASPIRATION.

AND FINALLY, I WANT TO ASSESS
THE STOMACH AND LISTEN
TO BOWEL SOUNDS,

AND SEE HOW THEY'RE
DOING WITH THAT.

AND WE'VE ALREADY TALKED
ABOUT THAT.

ALWAYS INSPECT BEFORE
YOU DO ANY ASSESSMENT.

YOU'RE LOOKING AT COLOR,
SYMMETRY, CONTOUR.

AND THEN YOU'RE GOING TO
LISTEN RIGHT LOWER QUAD,

GO AROUND CLOCKWISE, ONE
MINUTE IN EACH QUAD,

IF YOU DON'T HEAR A SOUND.

UP TO 5 MINUTES BEFORE
YOU SAY, NO BOWEL SOUNDS.

ALRIGHT. I WANT TO
DO ONE OTHER ASSESSMENT

BEFORE I START MEASURING MY
TUBE AND THAT IS,

MR. CURRY, COULD YOU BREATHE IN
AND OUT OF YOUR NOSE FOR ME?

AND I WANT TO PLUG ONE NOSTRIL
AND SEE HOW THE AIR PASSES.

LISTEN.

AND LISTEN, AND SEE IF I HEAR
MORE AIR FROM ONE NOSTRIL
OR THE OTHER.

AND I ALSO WANT TO TAKE
A LOOK IN THE NOSTRILS

AND MAKE SURE I DON'T DETECT
ANY DEVIATED SEPTUM.

ANY CURVATURE OR ANYTHING THAT
MIGHT KEEP THIS TUBE
FROM PASSING.

AND ASK, "DO YOU HAVE
A DEVIATED SEPTUM?

DO YOU HAVE ANY DIFFICULTY
BREATHING? HAVE YOU HAD
ANY NASAL SURGERIES?

ALRIGHT. WELL, EVERYTHING
SEEMS CLEAR.

I'M PROBABLY JUST GOING TO GO
OVER HERE ON THE RIGHT HAND
SIDE, IF YOU DON'T MIND.

I'M GOING TO PUT THE BED UP
A LITTLE BIT.

AND WHAT I WANT TO DO NEXT
IS MEASURE

SO THAT I HAVE THE TUBE
THE RIGHT LENGTH TO GO
INTO THE STOMACH.

- IF THEIR ANXIETY LEVEL'S TOO
HIGH, CAN WE GET THEM ANYTHING?

- POSSIBLY. IF THE DOCTOR'S
ORDERED SOMETHING AND IF
THEY'RE COMBATIVE

AND YOU DON'T THINK THEY'RE
GOING TO COOPERATE, YOU REALLY
NEED A SECOND PERSON.

BECAUSE THE NATURAL INSTINCT FOR
SOMEONE THAT'S CONFUSED

IS TO GRAB, AND THEY GRAB
AT YOUR HANDS.

AND IT'S VERY HARD TO SHUT
SOMETHING IN WHILE SOMEONE'S
GRABBING AT YOU THIS WAY.

SO YOU JUST REALLY NEED
SOMEONE TO HELP YOU

HOLD THEIR HANDS IF
THEY DON'T COOPERATE.

SO I'VE DONE THEM EVERY WHICH
WAY AND WHATEVER WORKS ON THAT.

- DIANE, DO YOU HAVE SOME
PROBLEMS WITH QUALITY, I MEAN --

- YES, I'M GOING TO TELL
YOU STORIES.

OH, THE SECOND HALF OF
THE SEMESTER IS STORIES

BECAUSE WE'RE DOING SOME
STUFF. ALRIGHT.

WHAT WE NEED TO DO IS, WE NEED
TO MEASURE FOR THE RIGHT LENGTH.

AND WHAT YOU WANT TO
DO IS TAKE YOUR TUBE

FROM THE TIP OF THE
NOSE TO THE EARLOBE

AND LOOK AND MAKE SURE THAT
YOU'RE AT THE END OF THE
XIPHOID PROCESS.

OKAY. ONCE YOU GET THERE, THEN
YOU JUST TAKE A LITTLE
PIECE OF TAPE

AND MARK IT.

YOU COULD LOOK AT THE LITTLE
BLACK LINES. BUT ONCE YOU'VE
PASSED IT THROUGH,

YOU CAN'T REMEMBER IF YOU'RE AT
THE FIRST OR THE SECOND LINE,
SO THAT'S A LITTLE RISKY,

WHEN YOU'RE DOING IT
BY THE LINE COUNT.

THE OTHER METHOD THAT YOU
COULD CONSIDER

IS THEY SAY THAT IF YOU MEASURE
50 CENTIMETERS ON YOUR TUBE

AND THEN DO THIS MEASUREMENT,

THAT THE MEASUREMENT BETWEEN
YOUR MEASUREMENT AND THE
50 CENTIMETERS

SMACK IN THE MIDDLE IS
THE OTHER MEASUREMENT.

DOES THAT MAKE SENSE?
IT'S A LITTLE WORDY.

BUT IT MAKES A LITTLE BIT LONGER
LENGTH, JUST TO MAKE SURE,
YOU'RE IN THE STOMACH.

SO 50 CENTIMETERS IS, AS LONG
AS YOU WOULD WANT IT TO BE.

YOU CAN DO THE TRADITIONAL
MEASURE WHICH IS EAR, NOSE.

IT DOESN'T REALLY MATTER WHICH
DIRECTION, XIPHOID PROCESS

AND THEN FROM THE 50 CENTIMETER
PART AND THE NOSE PART, IT WOULD
BE RIGHT IN THE MIDDLE.

SO IT WOULD BE ON THE OTHER SIDE
OF MY TAPE, THEORETICALLY.

OKAY.

I THINK IN YOUR PAPER, ALL I
PUT WAS JUST TO DO THIS ONE.

OKAY. AND THEN MARK IT.

YOU NEED A MARK SO THAT
YOU KNOW HOW FAR TO GO.

OKAY.

MY TUBE IS READY. I WANT TO
PUT A LITTLE BARRIER...

..HERE.

I WANT TO HAVE MY PH
PAPER READY TO GO.

WHAT PH ARE YOU LOOKING FOR
WHEN YOU MAKE YOUR ASPIRATE?

- 3 OR LESS.

- 3 IS A GOOD ONE.
WHAT'S SO GREAT ABOUT 3?

BECAUSE IT'S BELOW 6,
THAT'S WHAT'S GOOD ABOUT IT.

[LAUGHTER]

ALRIGHT, SO STOMACH CONTENTS
ARE USUALLY 6 AND BELOW.

INTERESTINGLY, THEY SAY,
ANYTHING ABOVE 3

IS MORE ACIDIC AND IT CAN CAUSE
ACTUALLY ASPIRATION PNEUMONIA.

IT PUTS THEM AT A GREATER RISK,
THE HIGHER THE NUMBER IS.

SO, YOU LIKE NUMBERS FOUR
AND BELOW FOR YOUR CLIENT

AND THAT'S USUALLY A PRETTY
SAFE INDICATOR

THAT YOU'RE IN THE STOMACH
RELATED TO PH.

NUMBERS BETWEEN 6 AND 7.5
USUALLY INDICATE LUNGS.

AND 7.5 AND ABOVE IS BOWELS.

SO, YOU NEED TO KNOW FOR SURE
WHAT KIND OF TUBE YOU HAVE.

DO YOU HAVE A TUBE THAT'S IN THE
STOMACH OR DO YOU HAVE ONE OF
THOSE FEEDING TUBES

THAT'S IN THE INTESTINES,
BECAUSE YOU'RE NOT GOING TO
PANIC AND TAKE THE THING

OR PULL ON IT IF YOU GET A 7.5,
IF IT'S IN A DOBHOFF TUBE,

THAT'S WEIGHTED DOWN
IN THE INTESTINES.

SO, MAKE SURE YOU KNOW
WHERE YOU'RE HEADING.

WORK HIS STOMACH
AND WE NEED A FOUR.

MAKE SURE YOU GOT PAPER THAT'S
THE RIGHT PARAMETERS.

SO YOU NEED PAPER THAT'S ONE TO
12 SO THAT YOU CAN GET
THE RIGHT PH.

OKAY.

GLOVES AT THIS POINT.

AND WE'RE PUTTING IT IN.

OKAY, ON A HUMAN BEING,

BEFORE I PUT IT IN, I WOULD TAKE
AND LUBRICATE WITH K-Y JELLY, 3
INCHES.

ON A MANNEQUIN, I'M GOING TO GET
SOME SILICON SPRAY.

AND OH, THIS STUFF IS EVER SO
SLIPPERY. I'M GOING TO GIVE
IT A SQUIRT.

AND IF YOU'LL GIVE IT A SQUIRT
IN THE NOSE, IT WILL REALLY
SLIDE IN GOOD.

OKAY.

- IS THAT THE GOOD NOSTRIL?
- I BELIEVE IT IS.

OKAY.

NOW, INTERESTINGLY, ON A PERSON,

YOU HAVE THIS VISUAL.
I KNOW YOU'RE VISUALS LIKE ME.

AND THE NOSE LOOKS LIKE
IT'S GOING UP

AND SO YOU HAVE THIS INCLINATION
TO WANT TO GO UP.

BUT YOU DON'T GO UP,
YOU GO DOWN.

AND YOU FOLLOW THE BASE PATH
OF MY --

I DON'T HAVE MY LITTLE
HEAD ANYMORE.

BUT DID YOU NOTICE HOW
THE NARIES GO STRAIGHT?

CHRISTINE, I WANT YOU TO
JUST HOLD UP THE NOSE.

WE'LL PUT YOU ON CAMERA HERE
FOR JUST A BRIEF MOMENT,
NICE [INDISTINCT].

SEE HOW THE -- FROM THE NARIES,
HOW IT GOES STRAIGHT ACROSS.

IF YOU GO UP, YOU GO UP
INTO THE TERMINATES.

IT'S STRAIGHT ACROSS.

AND YOU'RE ACTUALLY, KIND
OF, GOING TOWARDS THE EAR.

OKAY, SO DOWN AND TOWARDS THE
EAR. SO, MAKE SURE THE CURVE
IS DOWN.

ALRIGHT. HERE WE GO, MR. CURRY,
THIS IS GOING TO BE
A LITTLE UNCOMFORTABLE,

BUT IF YOU'LL JUST LET THIS
GO IN, AND I'M GOING
TO PASS AND PASS

TILL IT GETS TO THE BACK
OF YOUR THROAT.

[CLICKING]

OKAY, AND STOP. PULL BACK A
LITTLE SO THEY'RE NOT GAGGING
AND LET THEM GET COMPOSED.

IT'S NOT COMFORTABLE.

CAN YOU IMAGINE SOMETHING
UP YOUR NOSE? I MEAN, URGH!

ALRIGHT. AT THIS POINT I WANT
TO TAKE MY FLASHLIGHT AND LOOK.

AND SURE ENOUGH, THAT TUBE IS IN
THE BACK THERE. IT'S BEAUTIFUL.

I'M GOING TO GIVE
MY CLIENT THIS CUP...

..WHICH THEY WOULD HOLD AND
BE READY TO DRINK FROM.

AND I'M GOING TO TELL MY CLIENT,
MR. CURRY, IF YOU COULD PUT
YOUR CHIN TO YOUR CHEST,

THAT WILL CLOSE OFF THAT AIRWAY.
AND THEN I'M GOING TO HAVE YOU
DRINK HERE ON JUST A SECOND,

IF YOU CAN JUST HOLD THE CUP."
BUT I WANT TO DO ONE OTHER
LITTLE THING.

REMEMBER, MY TUBE
IS GOING LIKE THIS?

IT CAN COME OUT THE MOUTH,
IF I KEEP THAT CURVE GOING.

IF YOU'LL TAKE YOUR TUBE AND
GIVE IT A LITTLE HALF TWIST,

NOW THE CURVE
IS GOING THE OTHER WAY

AND THEN IT WILL GO TOWARDS
THE BACK OF THE THROAT

AND YOU WON'T KEEP SENDING IT
DOWN THAT AIRWAY OR
OUT THE MOUTH.

A LITTLE TRICK TO REMEMBER, NOT
IN THE BOOK. IT'LL HELP YOU.

OKAY, SO I'M GOING TO GIVE A
LITTLE TWIST, CHIN TO CHEST.

AND, "ALRIGHT, MR. CURRY,
IF YOU COULD START DRINKING,

I'M GOING TO PASS THIS
THE REST OF THE WAY DOWN."

AND HE STARTS DRINKING,
DRINKING, DRINKING, DRINKING,

DRINKING, DRINKING AND I JUST
KEEP PUTTING IT ON DOWN
TILL I REACH MY TAPE.

AND I SAY, "OKAY, THAT'S
GOOD, THAT'S ENOUGH,"

ALRIGHT. NOW, AT THIS POINT,

YOU COULD TAKE A LITTLE PIECE
OF TAPE,

IF YOU FEEL LIKE YOU'RE GOING
TO GET SOME SLIPPAGE.

IT'S GOING JUST
A LITTLE BIT FURTHER.

AND JUST KIND OF HAVE IT JUST
STICK HERE FOR A SECOND SO
YOU CHECK PLACEMENT.

RIGHT? BECAUSE YOU NEED TO KNOW
IF IT'S IN THE RIGHT PLACE

BEFORE YOU GO VIGOROUSLY
TAPING IT ALL UP.

SO, WHAT I WANT TO DO HERE IS

ASPIRATE AND GET SOME
RESIDUAL CONTENTS

AND I ALSO WANT
TO GET ENOUGH FOR PH.

CHECK THE PH.

AND SEE WHAT IT IS BEFORE
I GO SHOVING THIS BACK IN.

YOU WANT TO MAKE SURE
IT'S 4 BELOW.

THEN I CAN RETURN
IT OR LEAVE IT OUT.

IT JUST DEPENDS ON WHAT YOU'RE
DOING, I MEAN, AT THAT POINT.

I'M GOING TO CONNECT
IT RIGHT NOW.

AND THEN ONCE I'VE
VERIFIED PLACEMENT,

I WANT TO ASK YOU A COUPLE OF
OTHER THINGS. CAN YOU SPEAK?

YOU KNOW, I CHECKED THE
BACK OF THE THROAT.

IF THEY CAN TALK, THAT'S USUALLY
A PRETTY GOOD INDICATOR YOU'RE
NOT DOWN THE TRACHEA

SO THEY CAN SPEAK. I'VE SEEN
THE TUBING IN THE BACK
OF THE THROAT.

I OPEN THEIR MOUTH, AND MAKE
SURE IT'S NOT ALL COILED UP
BACK THERE.

I HAD THE FUNNIEST THING. THIS
CONFUSED SWEET, LITTLE OLD LADY,

I WAS PUTTING THE TUBE DOWN,
I CAN'T REMEMBER WHAT
IT WAS FOR.

BUT SHE JUST SMILED AT ME, AND I
SHOVED THE LITTLE TUBE DOWN
AND SHE JUST SMILED

AND I SAID, "CAN YOU TALK?" AND
SHE WENT...AND THEN SHE WENT...

THE WHOLE THING COILED UP
ON HER TONGUE AND IT
HAD COME OUT.

AND I WAS LIKE, "OH, SHOOT."

YOU KNOW, SO I HAD TO PULL
IT OUT AND THEN START OVER
BECAUSE THAT WAS NO GOOD.

AND SHE DIDN'T CARE WHAT
I DID TO HER REALLY.

BUT YOU JUST DON'T ALWAYS
KNOW SOMETIMES.

SO THAT'S WHEN THAT LITTLE
TWISTY THING WILL HELP.

ALRIGHT. SO MY CLIENT CAN
SPEAK, PLACEMENT'S GOOD,

YOU CAN TAKE THIS OLD
MARKER TAPE OFF...

..SO THAT YOU DON'T HAVE A
BUNCH OF STUFF ON THERE.

AND THEN WHAT I DID WAS I PUT
THE WHOLE PIECE OF TAPE
ON ONE SIDE,

ON THE NOSE AND THEN TAKE YOUR
SPLIT AND WRAP IT AROUND
THE TUBE ONE WAY.

AND THEN TAKE YOUR OTHER
AND THEN WRAP IT AROUND
THE TUBE THE OTHER WAY.

AND THAT WILL STABILIZE
THAT ON THE NOSE.

AND THEN IF YOU FEEL LIKE YOU
NEED ONE MORE PIECE ACROSS
THE BRIDGE OF THE NOSE,

BECAUSE THEY DO TEND
TO SLIDE OFF,

YOU COULD PUT ONE MORE ACROSS
THE BRIDGE LIKE THAT.

THOSE MANUFACTURED NG
TUBES THAT I'VE USED,

IT'S A LITTLE PLASTIC
BAR WITH THIS RING.

AND I ALMOST ALWAYS
HAVE STABILIZED THOSE

WITH ANOTHER PIECE ACROSS THE
BRIDGE BECAUSE THEY DO
TEND TO SLIDE OFF

AND THEY DON'T STAY STABLE.

ALRIGHT.

HE'S DOING FINE HERE.

I WANT TO MEASURE
THE LENGTH OF TUBING

THAT IS COMING OUT OF HIS NOSE.

AND SO, I'M GOING TO MEASURE
FROM HIS NOST-- HIS NOSE HERE
TO THE END.

AND I'M GOING TO SAY, TO THE END
OF THE WHITE PIECE WHICH
IS 29 INCHES.

SO THAT THE NEXT PERSON KNOWS
IF THERE'S ANY QUESTION
AS TO PLACEMENT,

THEY CAN MEASURE THE LENGTH,
LOOK AT THE BACK OF THE THROAT.

I MEAN, WHAT IF THEY'RE NOT
GETTING ASPIRATE OUT,

HOW DO YOU KNOW IT'S
IN THE RIGHT PLACE?

I'M ALSO GOING TO -- ONCE I'M
ALL DONE HAVE HIM GET
A CHEST X-RAY,

BECAUSE THAT'S REALLY THE ONLY
WAY THAT YOU CAN ABSOLUTELY KNOW

THAT YOU'RE IN THE RIGHT PLACE,
IS CHEST X-RAY.

SO WE'LL
GET THAT IN A BIT.

LET ME GO AHEAD
AND PLUG THIS FOR NOW.

AND I WANT TO PUT ON -- WASTED
ONE OF MY PIECES OF TAPE.

SO, I'M GOING TO PUT ON ONE
OTHER PIECE OF TAPE HERE.

AND YOU WANT TO JUST CURVE
THIS A LITTLE BIT,

PUT A PIECE OF TAPE ON THE
TUBING AND DOUBLE BACK IT.

AFTER WE GET THIS SILICON GOING,
EVERYTHING IS SO SLIPPERY.
NOTHING STICKS.

THAT'S GREAT.

AND THEN GET YOUR SAFETY PIN,
BECAUSE YOU DON'T WANT IT
HANGLING IN --

DANGLING LIKE THAT BECAUSE IT
WILL PULL ITSELF OUT OF PLACE.

SO, PIN THE TAPE, NOT
THE TUBING TO THE GOWN

SO THAT IT'S STABLE HERE AND NOT
CAUSING TRAUMA ON THE NOSE.

OKAY, GET MY CHEST X-RAY. GO
AHEAD AND LEAVE THEM UP.

IF THEY NEEDED TO HAVE HIM
SUCTIONED, YOU WOULD PUT
HIM TO SUCTION.

AND THAT'S IT.
HE LOOKS WONDERFUL.

HOW ARE YOU DOING? IT'S
NOT COMFORTABLE, HUH?

ALRIGHT, WELL, WHEN YOU
HAVE THAT TUBE IN,

WE WANT TO MAKE SURE TO
GIVE YOU GOOD ORAL CARE.

SO WE'LL LEAVE YOU SOME
TOOTHETTES SO THAT YOU CAN
FRESHEN UP YOUR MOUTH.

AND THEN IT WOULD BE GOOD
IF YOU AT LEAST BRUSH YOUR
TEETH MORNING AND NIGHT,

AND EVEN AFTERNOON WOULDN'T
HURT ANYTHING.

SO, GOOD ORAL HYGIENE. MAKE
SURE YOUR CLIENT TURNS
EVERY 2 HOURS.

JUST BECAUSE THEY HAVE A TUBE IN
DOESN'T MEAN THEY HAVE TO SIT
LIKE THIS FOREVER.

THEY NEED TO MOVE AROUND.
MOST OF THE TIME, YOU DO WANT
THEIR HEAD UP A LITTLE BIT

BECAUSE IT PREVENTS
ASPIRATION, THAT'S WHY.

SO, I WOULD WASH MY HAND,
CLEAN UP MY MESS.

WASH MY HANDS. AND DOCUMENT
THE SIZE OF TUBE I USED,

WHICH NOSTRIL IT WAS IN,

HOW THEY TOLERATED IT AND WHAT
KIND OF CONTENTS I GOT BACK,

HOW I VERIFIED
FOR PLACEMENT.

SO YOU WANT TO NOTE
THE CHEST X-RAY

AND I'D WANT TO NOTE THAT
THE CLIENT COULD SPEAK,

THAT THE PH WAS WHATEVER
THE PH WAS.

TUBE VISUALIZED IN THE
BACK OF THE THROAT AND
UP TO SUCTION.

AND I GOT SO MUCH COFFEE GROUNDS
BACK, POOR SOUL.

OKAY. LET'S TALK ABOUT
SOME STORIES HERE.

THE CLIENT COMES IN AND
THEY HAVE A GI BLEED.

A GI BLEED COME IN ONE DAY, AND
I PUT QUITE A FEW TUBES DOWN,

SO I REALLY WASN'T ANTICIPATING
MUCH OF A DISASTER.

AND GOT MY PARAPHERNALIA
TOGETHER, AND I NOTICED THAT HIS
STOMACH WAS REALLY DISTENDED.

SO HE'D BEEN BLEEDING FOR A
WHILE AND HE WASN'T PASSING WELL
THROUGH THE BOWELS

AND HE JUST HAD COFFEE GROUNDS,
HE HAD BEEN THROWING
UP AT HOME.

AND HE REALLY WAS
A MISERABLE, MISERABLE MAN.

SO I HAD ALL MY SUPPLIES
TOGETHER AND I STARTED PUTTING
THE TUBE DOWN

AND IT WAS JUST LIKE TAKING
THE FINGER OUT OF THE DYKE.

AS SOON AS I HIT HIS STOMACH
CONTENTS, HE JUST RETCHED.

AND THIS TUBING, WHEN IT HIT THE
FLUID, WHOOSH, WHOOSH, WHOOSH OF
COFFEE GROUND.

I HAD COFFEE GROUNDS EVERYWHERE,
I HAD BLOOD EVERYWHERE.

HE WAS STILL --
I HAD BODY FLUIDS EVERYWHERE

I HADN'T PLUGGED MY END.

SO I WASN'T READY
FOR THAT, AT ALL.

SO I MIGHT SUGGEST THAT IF YOU
HAVE SOME DISTENSION

THAT'S PRETTY VISIBLE AND
THEY'RE BLEEDING AND YOU KNOW
THERE'S STUFF ON THE STOMACH

AND YOU'RE PUTTING A TUBE IN
FOR RELIEF, YOU MIGHT WANT
TO PLUG THIS.

AND YOU MIGHT WANT TO PUT A
COUPLE OF CHUX DOWN

INSTEAD OF YOUR ONE LITTLE
TOKEN CHUX, AND THIS,

WHAT A JOKE, HE NEEDED
A BOWL.

SO, BE PREPARED. I JUST WASN'T.
AND IT WAS HUGE, IT WAS A MESS.

AND, YOU KNOW, IT'S NOT LIFE OR
DEATH, HE NEEDED A TUBE,
HE NEEDED THE RELIEF.

OH, I HAD A HUGE MESS
ON MY HANDS.

HE FELT REALLY BAD. BUT WHAT DO
YOU DO? IT WAS JUST A MESS.

I TOLD YOU ABOUT THE
TUBE OUT THE MOUTH.

ANOTHER TRICK TO PUTTING
TUBES DOWN

IS SOMETIMES ON THE
TUBES THERE'S --

THEY NEED TO BE A LITTLE
STIFFER. PART OF THE PROBLEM
IS THEY'RE SOFT,

AND THAT'S WHY THEY KEEP
COMING OUT THE MOUTH.

SO IF YOU'LL TAKE YOUR TUBE AND
PUT IT ON ICE FOR A FEW MINUTES,

THAT'LL STIFFEN IT UP
A LITTLE BIT

AND YOU'LL HAVE BETTER LUCK
GETTING IT TO GO STRAIGHT

THAN IF YOU JUST PUT IT IN,
ROOM TEMP.

I DON'T HAVE ANY MORE STORIES.
I DON'T REMEMBER ANY MORE
STORIES TO OFFER.

ONLY THE BASIC ONES
I THINK ON NGS.

COMBATIVE CLIENTS, WHEN THEY'RE
CONFUSED, THEY SWAT AT YOU, SO
YOU NEED SOMEONE TO HELP YOU.

AND IF YOU CAN JUST TALK THROUGH
WITH PEOPLE, WHAT THEY'RE
SUPPOSED TO DO,

MOST OF THE TIME, THEY'LL
COOPERATE PRETTY WELL.

THE MAIN THING IS IT'S PRETTY
UNCOMFORTABLE AS IT PASSES

THROUGH THE NARIES PART IN THE
BACK OF THE NASAL PHARYNX, IT'S
A LITTLE UNCOMFORTABLE.

- AT CLINICAL YESTERDAY
WE WERE REVIEWING,

MY PATIENT'S CHARTS AND I
NOTICED, SHE'D BEEN HERE FOR 12
DAYS,

BUT ABOUT THE SECOND DAY SHE
PULLED OUT HER TUBE, IS THAT
RELATIVELY COMMON?

BECAUSE WE WERE TALKING ABOUT A
COUPLE OF CASES AND THEY WERE --

- COMMON IS RELATIVE. IT DEPENDS
ON HOW CONFUSED THEY ARE.

MY CONFUSED CLIENTS, I'VE HAD
WITH FEEDING TUBES PULL THEM
OUT ALL THE TIME.

AND THAT'S WHY THEY'RE NOT A
GOOD TREATMENT

FOR CONFUSED PEOPLE
THAT NEED FEEDING TUBES

BECAUSE THEY PUT THEM ON A
HIGH RISK FOR ASPIRATION.

THAT'S WHY YOUR G TUBES
ARE BETTER.

IF THEY'RE CONFUSED AND
YOU STILL NEED IT,

BECAUSE YOU'RE DOING THE LAVAGE,

YOU'RE PULLING OFF ON THE
DECOMPRESSION, BOY,
YOU'RE IN A PICKLE.

THAT'S WHEN RESTRAINTS OR
SEDATION OR SOMETHING,

FAMILY MEMBERS THERE
ALL THE TIME TO HELP YOU.

AND THEN WE HAVE TO REPLACE.

YOU KNOW, THERE COMES A POINT OF
YOU CALLING THE DOCTOR
AND SAYING,

"THIS IS NOT WORKING. I PUT IT
IN, THEY PULL IT OUT. THIS
IS TOO TRAUMATIC."

SO, ONCE OR TWICE, I MEAN
WE'LL PUT THEM BACK IN.

BUT IF THIS IS LIKE
EVERY 8 HOURS,

THIS IS OUT OF CONTROL,
NOT WORKING.

SO, I DON'T KNOW, COMMON. BUT IT
HAPPENS A LOT. AND WE
REPLACE THEM.

THEY CAN GET STUCK ON THINGS AND
GET PULLED PUT OR DISPLACED.

DO YOU HAVE A QUESTION
OVER HERE?

IF YOU DON'T GET FLUID BACK TO
CHECK PH, THAT'S, KIND OF,
A CHALLENGE, RIGHT?

WHAT DO YOU DO
IF THERE'S NO FLUID?

SO YOU WANT TO CHECK ALL
OF YOUR INDICATORS

AND MAKE SURE THAT THE TUBE
IS THE SAME LENGTH,

MAKE SURE THAT YOU SEE
TUBING IN THE BACK,

MAKE SURE THEY CAN SPEAK.
AND IF YOU JUST DON'T
GET ANYTHING BACK,

I MIGHT HAVE THEM ROTATE
POSITIONS, YOU KNOW, AND
SEE IF I CAN CATCH SOMETHING

IF THEY ARE LAYING ON ONE
SIDE AS OPPOSED TO ANOTHER.

PROBABLY LAST BUT NOT LEAST,
I'D TRY THE AIR IN THE STOMACH

JUST TO SEE IF I HEARD, EVEN
THOUGH IT'S NOT RECOMMENDED.

BUT ALL MY OTHER SIGNS
ARE INTACT.

THEN I WOULD GO AHEAD
WITH MY FEEDING OR

MY ASPIRATION, AS LONG AS
EVERYTHING ELSE IS EXACTLY
THE SAME.

LENGTH OUT HERE, TUBE DOWN
THE BACK, SPEAKING,

NO VISIBLE CHANGE, I JUST
AM NOT GETTING FLUID BACK.

MOST OF THE TIME YOU WILL, BUT
THERE IS THAT RARE INSTANCE,
IT'S, LIKE, WHAT DO YOU DO?

PANIC? TAKE THE TUBE OUT?
CALL THE DOCTOR?

THAT'S JUST NOT WHAT YOU DO.

YOU'RE GOING TO CHECK EVERYTHING
AND THEN PURSUE IT.

OKAY. THEY HAVE A NEW TREATMENT.
I GAVE YOU A LITTLE PARAGRAPH.

THAT'S I WANT YOU TO LOOK AT,
IN OF YOUR ARTICLES
ON CAPNOMETRY.

THEY FOUND THAT WITH CAPNOMETRY
THAT THEY CAN READ

THE CARBON DIOXIDE ON
RESPIRATORS

TO SEE HOW THE AIR EXCHANGES.

AND THEY FOUND THAT IF THEY
HOOKED THE CAPNOMETRY READER
TO THE END OF THE TUBE,

IF IT READ IN CERTAIN
PARAMETERS,

THEN IT WAS NOT IN THE LUNG,
BUT IF YOU GOT A CERTAIN READING

WITH THE CARBON DIOXIDE,
IT WAS IN THE LUNG.

AND IT WAS 100% CORRECT ON
EVERYONE THAT THEY CHECKED.

SO, THEY WERE RESEARCHING AND
IN THE PROCESS OF DECIDING

IF THEY WOULD RATHER
USE THAT THAN X-RAY.

BECAUSE, THE X-RAY ISN'T THAT
SAFE TO BE USING ON CLIENTS
ALL THE TIME.

AND IF IT'S 100% EFFECTIVE

WELL, THEN WE GOT A
GREAT TOOL AT BEDSIDE

TO USE INSTEAD OF ALL THIS PH,
WE CAN'T GET ANYONE TO
USE ANYWAYS.

YOU KNOW, AND MESSING
IN THE BODY FLUIDS.

JUST OPEN THE END, CHECK FOR
EXCHANGE AND YOU'RE GOOD TO GO.

SO, ANYWAYS INTERESTING LITTLE
ARTICLE AND I THOUGHT THAT
WOULD BE HELPFUL FOR YOU.

I ALSO PUT IN A WONDERFUL
ARTICLE THAT HAS PICTURES

AND DESCRIPTIONS OF ALL THE
DIFFERENT KINDS OF TUBES

SO THAT YOU CAN REVIEW
WHAT THEY'RE FOR,

WHAT THEY LOOK LIKE AND HOW
DO I KNOW WHAT TO PICK

WHEN IT COMES MY TURN TO
PUT AN NG IN FOR SUCTION.

YOU'RE GOING TO PICK THE
SALEM SUMP TUBE 14 TO 6,

BUT IT GIVES YOU SOME OF THOSE
PARAMETERS TO HELP YOU DECIDE
WHAT YOU NEED.

ALRIGHT. AFTER YOU PUT YOUR TUBE
IN, THEN YOU GOT TO BC
YOUR TUBES.

SO WE CHECKED OUR
DOCTOR'S ORDERS.

AND THE DOCTOR SAID,
"BC THE TUBE."

WE'RE GOING TO GATHER
UP OUR EQUIPMENT.

THE EQUIPMENT GATHERING IS
MUCH SIMPLER ON THIS ROUND.

YOU NEED A PAPER TOWEL AND
SOMETHING FOR ORAL HYGIENE
AND YOUR SYRINGE.

SO THE CHUX WOULD PROBABLY GET
PUT ACROSS THE CHEST.

WASHED MY HANDS AND IDENTIFIED
MY CLIENT, CONRAD CURRY AND
PROVIDE HIM PRIVACY.

ALRIGHT, MR. CURRY, YOU'RE DOING
SO GOOD. WE'RE GOING TO
TAKE THAT TUBE OUT.

IT'S A LITTLE UNCOMFORTABLE
COMING OUT COS IT'S GOT TO COME
OUT THE SAME WAY IT WENT IN,

BUT WE'RE NOT FOCUSED SO MUCH,
IT JUST SLIDES OUT.

WHAT PATIENTS TELL ME IS THAT
BECAUSE THE TUBE HAS BEEN
SITTING IN THE STOMACH

THAT SOME OF THAT BILE,
THEY CAN, KIND OF, TASTE IT
WHEN IT GETS UP TO THE NASAL,

TO THE BACK OF YOUR THROAT
THROUGH THE NOSE AREA.

SO, THERE'S KIND OF A BITTER
TASTE, SO WE'LL GIVE YOU
SOME GOOD ORAL CARE

AND SEE IF WE CAN GET
THAT TAKEN CARE OF.

AND A LITTLE BIT OF BURNING,
JUST BECAUSE IT'S PASSING
THROUGH THE NOSE.

SO. BUT IT'S JUST A QUICK
PULL OUT AND IT'S DONE.

SO, WHAT I WANT TO DO HERE IS...

..FIRST, I'M GOING TO JUST
PUT SOME AIR IN THE TUBE.

EVERYTHING LOOKS FINE, BUT
WHAT I'D LIKE TO DO

IS I'D LIKE TO CLEAN
EVERYTHING OUT OF THE TUBE.

REMEMBER WHEN YOU WERE
EMPTYING YOU IV TUBING,

AND THERE WAS FLUID IN IT, BUT
YOU NEEDED TO GET ALL
THE FLUID OUT.

AND THE HIGHER YOU HOLD IT,
THE FLUID LEVEL DROPS,

THE HIGHER YOU HOLD.
WELL, THE SAME THING.

IT SITS IN THE STOMACH, THE TUBE
AND IT MAY HAVE, KIND OF,
LIKE A STRAW DOES,

THAT LITTLE BIT OF FLUID THAT'S
SITTING IN THE BASE OF THE TUBE.

IF YOU DON'T GET THAT FLUID
OUT, YOU GET DRAG.

AND AS YOU PULL THE TUBE UP,
THEN THAT FLUID STARTS
COMING OUT OF THE TUBE.

AND SO, AGAIN, YOU HAVE
RISK OF ASPIRATION

AND THEN GETTING BILE AND
STOMACH CONTENTS IN THE
THROAT AREA.

SO, WE WANT TO CLEAR THAT OUT.

SO YOU JUST GO AHEAD AND PUT
IN 20 TO 30 CC'S OF AIR,
CLEAR YOUR TUBING,

AND THEN LEAVE THE END
OF THE TUBING PLUGGED.

IF THE END OF THE TUBING
IS PLUGGED,

YOU WON'T HAVE THAT EXCHANGE
OF FLUID, IF THERE IS A
LITTLE BIT OF FLUID.

BUT WE CAN'T HELP WITH WHAT'S ON
THE OUTSIDE. YOU KNOW, IT'S BEEN
SITTING IN THE STOMACH

SO IT'S STILL GOING TO BE NOT
PERFECT, BUT THAT WILL HELP.

ALRIGHT. MR. CURRY, THERE'S ONE
THING THAT I NEED FOR YOU TO DO.

I'M JUST GOING TO TAPE IN THIS
HERE FOR YOU.

IS I'M GOING TO ASK YOU TO HOLD
YOUR BREATH WHILE I PULL
THE TUBE OUT,

AND THAT WILL KEEP THAT BILE
FROM GOING INTO YOUR AIRWAY.

SO, IF YOU COULD JUST HOLD YOUR
BREATH FOR A SECOND,
NOT VERY LONG,

THAT WILL BE HELPFUL.

AND ALL I'M GOING TO DO HERE
IS PUT A PAPER TOWEL HERE

SO THAT I CAN CATCH THE
TUBE WHEN IT COMES OUT.

SO IF YOU COULD TAKE A GOOD
DEEP BREATH AND HOLD IT.

PULL, PULL, PULL, PULL.
CATCH THE -- AND OKAY,

YOU CAN BREATHE.
AND ENCASE IT --

THESE ARE AWFUL.

AND THEN YOU CAN PUT THE GLOVES
ON AGAIN TO GIVE ORAL CARE
AND GIVE NASAL CARE.

THAT'S THE OTHER THING, I
DON'T REMEMBER IF IT'S ON
YOUR SHEET OR NOT,

BUT WHEN THE TUBE WAS IN, YOU
NEED TO CHECK THEIR NOSE
EVERY 4 HOURS,

AND MAKE SURE YOU CLEAN
AROUND THE NARIES

AND CHECK IT FOR ANY KIND
OF PRESSURE ULCERATION.

ALRIGHT, HERE YOU GO,
AND HERE'S THE KLEENEX.

YOU NEED TO BLOW YOUR NOSE.

AND THEN ORAL CARE,
CLEAN THE MOUTH.

AND THEN WASH YOUR --
CLEAN UP YOUR SUPPLIES.

WASH YOUR HANDS AND DOCUMENT.

AND THEN YOU WANT TO BE
OBSERVING YOUR CLIENT.

WHAT WOULD YOU BE OBSERVING
YOUR CLIENT FOR?

- DISTENSION.
- DISTENSION, UH-HUH.

WATCHING POSSIBLE ASPIRATION.

BUT DISTENSION, ARE THEY
TOLERATING NOT HAVING THE
TUBE ANY MORE TO SUCTION?

SO, WATCHING THEIR BOWELS,

MAKING SURE THAT THEY'RE
PASSING FLUIDS.

USUALLY, YOU START THEM
OFF ON ICE CHIPS

AND THEN CLEAR LIQUIDS AND MOVE
THEM ADVANCE AS TOLERATED AS
BOWEL SOUNDS GET ACTIVE

AND THEY'RE ABLE TO
TOLERATE THEIR FOODS.

ALRIGHT. ONE OTHER STORY
SCENARIO WE NEED TO CONSIDER,

AND THAT IS
WHEN THE TUBE IS IN,

YOU HAVE A CLIENT THAT
HAS AN NG TUBE IN,

AND THAT'S FOR DECOMPRESSION.

RIGHT? DECOMPRESSION BEING...

- AIR.

- GET THE AIR AND THE BODY
FLUIDS OFF THE STOMACH

SO THE BOWELS CAN TAKE A REST
AND IT SHOULD RELIEVE NAUSEA.

RIGHT? IF YOU DON'T HAVE
ANYTHING IN YOUR STOMACH,
WHAT'S THERE TO THROW UP?

IT'S NOT EVEN A DRY HEAVE.

YOU SHOULD RESOLVE NAUSEA AND
VOMITING WITH AN NG TUBE,

BECAUSE IT'S TAKING OFF
STOMACH CONTENTS.

ALRIGHT. YOUR CLIENT
HAS BEEN HAVING THEIR NG IN,

AND THEY'VE BEEN GETTING,
OH, I DON'T KNOW,

ABOUT 400 CC'S OFF A SHIFT
OR 600 CC'S OFF PER SHIFT.

AND YOU COME IN AND YOU LOOK AT
THE BOTTLE AND THERE'S A COUPLE
OF 100 IN THERE.

AND NOW YOUR CLIENT IS
COMPLAINING ABOUT NAUSEA.

WHAT'S THE PROBLEM?

- IT'S NOT...VACUUMING IT.
- IT'S NOT VACUUMING IT.

IT'S NOT VACUUMING
IT OUT, EXACTLY.

THEY GOT A BLOCKAGE SOMEWHERE.

YOU NEED TO, AT THAT POINT --

GLOVES, GET YOUR LITTLE SYRINGE.

AND TWO WAYS. YOU CAN DO IT WITH
AIR OR YOU CAN DO IT
WITH SALINE.

GET SOME SALINE,
COME DISCONNECT

AND THEN, WHOOSH, RINSE.

IRRIGATE THAT THING AND SEE
IF THAT'S BLOCKED,

IF THAT'S WHAT THE TROUBLE IS.

AND THEN, WHOA, ALL OF A SUDDEN,
FLUID STARTS COMING THROUGH.

AND YOU GO, "OH YEAH, BLOCKED."

OKAY. SO, COMPLAINTS
OF NAUSEA, COMPLAINTS --

CHANGES IN VOLUME USUALLY
MEAN BLOCK TOO.

YOU NEED TO IRRIGATE,
AIR, SALINE,

WHATEVER IS APPROPRIATE
FOR YOUR CLIENT. ALRIGHT.

- WE WERE DOING IT VERY
PRECAUTIONARY,

LIKE, EVERY 2 HOURS ANYWAYS,
JUST TO DO IT.

- JUST TO MAKE SURE?
- YEAH.

- I HAD A CLIENT THAT I DID
THAT ON AND HERE IS
STORY NUMBER 800. OKAY.

THEY HAVE A SALEM SUMP TUBE.

ALRIGHT.

SO THE SALEM SUMP IS DOWN
INTO YOUR CLIENT.

AND I WALK IN THE ROOM.

AND THERE' -- IT'S CONNECTED TO
SUCTION, SO THIS IS OFF.

AND I WALK INTO THE ROOM AND
THERE'S BILE IN A BIG PUDDLE
ON THE BED.

AND IT'S COMING OUT THIS.

WHAT'S THE PROBLEM?

- THE OTHER SIDE'S STUCK.

- UH-HUH. I GOT BLOCKAGE AGAIN.

THIS SIDE'S BLOCKED

AND SO MY AIR VENT'S NOW
TURNED INTO MY BILE VENT

AND I GOT A BIG MESS.

SO YOU CAN CLEAR THIS VENT
WITH AIR AND GET THE
BILE OUT OF THERE.

IF THAT DOESN'T HELP YOU, ONE
IOTA. GET THE BILE OUT.

BUT THEN THIS TUBE NEEDS TO
BE DISCONNECTED AND IRRIGATED

SO THAT YOU CAN CLEAR
THE BLOCKAGE

AND MAKE SURE THAT YOU GOT
FLUIDS COMING OUT HERE,
AIR COMING OUT HERE.

SO IF YOUR EQUIPMENT'S
NOT WORKING RIGHT,

DON'T JUST GO,
"OH, WHAT A MESS."

YOU GOT A PROBLEM. IT'S NOT
SUPPOSED TO DO THAT

AND IT'S USUALLY RELATED
TO BLOCKAGE.

OKAY, I THINK THAT'S A LOT
FOR A TUBE.

OKAY.

I WANT TO SHOW YOU A LITTLE
SEVEN-MINUTE VIDEO

OF THE BABY GETTING AN OG
FEEDING, AN OROGASTRIC FEEDING.

WE GIVE BABIES FEEDINGS
A LOT OROGASTRICALLY.

WE PUT A TUBE DOWN WHEN
THEY'RE FIRST BORN,

BECAUSE ONE, THEY MAY HAVE
RESPIRATORY DISTRESS,
THEY'RE PREMATURE

OR, ANYTIME THAT THEY SUCK ON
THE BOTTLE, THEY GET, LIKE BLUE.

AGAIN, RESPIRATORY DISTRESS.
THEY'RE NOT ABLE TO COORDINATE

THEIR SUCKING AND THEIR
BREATHING AT THE SAME TIME.

AND SO, WE'LL OG THEM FOR A
WHILE, OROGASTRIC FEEDING.

SO I WANT TO SHOW YOU WHAT THAT
LOOKS LIKE, WHICH BY THE WAY,

I DID PASS THE TUBE ONE TIME
THROUGH SOMEONE'S AIRWAY

AND I PUT IT DOWN IN THEIR
AIRWAY, A LITTLE --

ANOTHER LITTLE CONFUSED OLD LADY
AND ALL OF A SUDDEN

I JUST NOTICED HER LITTLE
LIPS GETTING BLUER AND
BLUER AND BLUER.

THERE WAS NO QUESTION THAT
I WAS IN THE WRONG SPOT.

SHE COULDN'T TALK TO ME,
SHE WAS CONFUSED.

BUT YOU WILL GET SIGNS THAT
THINGS ARE NOT RIGHT.

AND THAT WAS THE SIGN I GOT
WAS THE CIRCUMORAL CYANOSIS
RELATED TO WRONG PATH.

SO, LOOK AT YOUR WHOLE
CLIENT, DON'T JUST THINK,
"OH GOOD, I'M DONE."

LOOK AT THEIR FACE, LOOK
AT THEIR COLOR, LOOK AT
THEIR RESPIRATION,

SEE HOW THEY'RE DOING BEFORE
YOU JUST...

SAY, "OH, GOOD."

ALRIGHT, LET'S LOOK
AT THIS VIDEO

WHERE THEY MAY KEEP
IT IN AS AN NICU,

LITTLE TWO-POUNDERS, AND THEY
ARE FEEDING THEM A LITTLE
MORE CONSTANTLY.

AND THEY DON'T WANT
TO TAKE HIM IN AND OUT,

SO THEY MAY LEAVE THAT ONE IN
FOR A PHASE, KIND OF, THING.

BUT, MOST OF THE TIME, IT'S
JUST BETTER TO TAKE IT OUT.

IT, KIND OF, CAUSES THEM TO
GAG A LITTLE BIT SOMETIMES,
AND THEN THEY ALSO SUCK ON IT.

AND SOMETIMES, THEY CAN'T
COORDINATE EVEN THE SUCKING
ON THE TUBE.

SO, JUST OUT.

SO QUICKLY, YOU'RE GOING
TO HAVE A BABY STATION.

- GOING BACK TO THE --
- UH-HUH?

- TO THE SIZE OR THE NUMBER
OF THE TUBE SIZE
- YES?

- IN CASE SMALL DIAMETERS
THAT ARE FRENCH.

- FRENCH. UH-UH.
THAT'S THE OPPOSITE.

ON THE GAUGE IS THE BIGGER THE
NUMBER, THE SMALLER THE NEEDLE.

BUT ON FRENCHES, THE SMALLER THE
NUMBER, THE SMALLER THE GAUGE.

SO, LITTLE 5 FRENCHER IS WHAT
YOU WOULD USE FOR A FEEDING

OR A LITTLE 8 FRENCHER.

AND THEY COME IN DIFFERENT
LENGTHS, AS YOU CAN SEE.

AND THIS WOULD BE WHAT THEY
MIGHT WANT TO USE IN A LITTLE --

IN AN NICU WHERE
THEY PUT IT DOWN

AND THEN THEY HANG THE FEEDING
ON TO A POLE AND SO YOU
NEED MORE LENGTH.

BUT WHEN YOU'RE DOING JUST A
LITTLE BY HAND, KIND OF, A DEAL,

AND YOU'RE JUST DOING IT REAL
CLOSE, THEN THE LITTLE
SHORT ONES WORK.

THE LITTLE 5 IS VERY LITTLE.

SO FORMULA PASSES EVER SO SLOWLY
THROUGH A LITTLE 5.

THE 8S ARE NICE, IT
MOVES PRETTY FAST.

BUT YOU DON'T WANT TO HAVE A
FEEDING GO IN, IN ONE MINUTE

JUST BECAUSE YOU HAVE TO THINGS
TO GO, PLACES TO SEE AND,
YOU KNOW, STUFF.

SO YOU STILL NEED TO HAVE YOUR
FEEDING TAKE AS LONG AS A
FEEDING WOULD TAKE.

SO YOU'RE LOOKING AT 20
MINUTES FOR A FEEDING.

SO, SLOW ISN'T ALWAYS BAD.

IT KIND OF FORCES YOU TO TAKE
THE TIME YOU NEED TO TAKE
INSTEAD OF...

THERE, GOOD. ARE YOU HAPPY,
BABY? WELL, YOU KNOW, IT
NEEDS TO TAKE SOME TIME.

ALRIGHT, SO WE HAVE OUR
DOCTOR'S ORDERS TO OG.

WE'RE GOING TO GATHER --
WASH YOUR HANDS,

GATHER UP YOUR EQUIPMENT AND I
HAVE BOTH SIZES OF TUBES OUT
AND AVAILABLE.

SO, ACTUALLY, I'M NOT EVEN GOING
TO HAVE YOU GATHER ANYTHING
FOR THIS ONE.

THE STATIONS WILL BE SET UP,
YOU'LL JUST COME TO YOUR STATION

AND MAKE SURE EVERYTHING IS
THERE, THAT SOME STUDENT DOESN'T
WALK OFF WITH SOMETHING.

BUT EVERYTHING SHOULD BE THERE.

WE HAVE A LITTLE BASIN JUST
TO CATCH OUR PH PAPER.

I HAVE A 30 CC -- 20 CC SYRINGE.

I HAVE WATER, I HAVE SOMETHING
TO MEASURE THE WATER.

I HAVE SOME TAPE, I'LL GET
A COUPLE OF PIECES OUT.

AND I HAVE A MEASURING TAPE
TO MEASURE THE GIRTH.

YOUR ORDER IS, IN THE PRETEND
WORLD OF FEEDING

THAT YOU'RE GOING TO GIVE
10 CC'S OF FORMULA,

BUT YOUR FORMULA IS
GOING TO BE WATER,

BECAUSE THAT'S WHAT
WORKS FOR OUR BABIES.

SO, WASH MY HANDS, GOING
TO IDENTIFY MY CLIENT,

AND PROVIDE PRIVACY
IF POSSIBLE IN THE NURSERY.

ONE OF THE THINGS YOU WANT TO
BE SURE ABOUT WITH YOUR BABY

IS THAT WHEN YOU'RE DOING YOUR
MEASURING AND HANDLING THE BABY,

MAKE SURE THE BABY HAS HAD THE
FIRST BATH. IF THE BABY HAS
NOT HAD THE FIRST BATH,

THEN YOU HAVE TO HANDLE THEM
WITH GLOVES BECAUSE THEY HAVE
MOTHER'S BODY FLUIDS ON THEM.

SO YOU CAN ASSUME
OUR BABY IS CLEAN,

AND WE'RE JUST DOING A FEEDING,
BUT THAT'S NOTEWORTHY.

ALRIGHT. THE FIRST THING
WE WANT TO DO HERE

IS CHECK OUR IV BANDS.

AND I DON'T KNOW IF
I EVEN HAVE ANY ON THESE.

WE HAVE SPECIAL LITTLE BABIES...

..ACTUALLY THEY'RE IN A LITTLE
BASSINET LIKE THIS.

AND THEY'RE LITTLE TINY CHEAP
BABIES I BOUGHT AT WAL-MART
FOR, LIKE, 5 BUCKS.

BUT THEY HAVE HOLES SO THAT WE
CAN PUT TUBES DOWN IN THEM.

SO YOU CAN MEASURE ON
THE DIFFERENT SIZES.

SOME OF THESE OTHER BABIES DON'T
HAVE HOLES IN THEIR MOUTH.

SO THAT'S A PROBLEM.

ALRIGHT. FIRST THING WE WANT
TO DO IS WE WANT TO MEASURE
THEIR ABDOMINAL GIRTH.

WHY DO YOU WANT TO DO THAT?

- FOR DISTENSION

- AGAIN, YEAH, CHECKING
FOR DISTENSION.

CHECK TO SEE HOW THEY'RE
HANDING IT.

AND SO GET YOUR ABDOMINAL
GIRTH ON YOUR BABY.

YOU WANT TO LISTEN TO
LUNGS AND BOWEL SOUNDS

SO THAT YOU HAVE A GOOD BASELINE

AS TO HOW THEY'RE TOLERATING
THEIR FEEDING.

ALRIGHT. THE NEXT
THING I WANT TO DO,

IF YOU TAKE YOUR BASSINETS,
YOU CAN DROP THEM LIKE THIS,

AND THIS LITTLE BAR WILL KEEP
THEM UP WHICH IS NICE FOR
DOING YOUR FEEDINGS.

THE NEXT THING I WANT TO DO
IS I WANT TO GET THE RIGHT
MEASUREMENT FOR THE BABY.

AND THAT IS, I WANT
TO TAKE FROM THE NOSE --

FROM THE EAR TO THE
NOSE AND THEN BETWEEN

THE XIPHOID PROCESS
IN THE UMBILICUS.

BECAUSE OF THE BABY ANATOMY,

WE NEED THE TUBE TO BE JUST
A LITTLE BIT LONGER.

SO NOW IT'S NOT TOO XIPHOID,
BUT RIGHT IN BETWEEN.

AND THEN ONCE WE HAVE THAT SPOT,

WE JUST WANT TO MARK IT WITH
A LITTLE PIECE OF TAPE.

AND THEN YOU WANT TO PAPOOSE
YOUR BABY NICE AND SNUG...

..SO THAT THEY DON'T SWAT
AT THE TUBE.

SO, GRAB ONE END TIGHT, YOUR
LITTLE TRIANGLE --

HAVE WE TALKED ABOUT THIS
BEFORE? WE DID. OKAY.

AND THEN PUT YOUR BOTTOM,
THE SCARFING UP AND THEN
FINALLY THE LAST ONE.

SNUG, SNUG, SNUG. AND THEN...

..RIGHT SIDE.

AROUND THIS WAY.

OKAY, IF I'M GOING TO
GIVE 10 CC'S OF FEEDING,

I'M GOING TO GO AHEAD AND
MEASURE IT...

IN YOUR LITTLE BOTTLE, AND WE'LL
JUST HAVE A BIG, OLD GLASS
OF WATER LIKE THIS.

HERE WE GO.

AND SYRINGE.

GLOVES.

- DO YOU SHUT THE BULB
SYRINGE OR [INDISTINCT]?

- THE BULB SYRINGE, YES,
SHOULD BE IN HERE

AND I WAS JUST TAKING A QUICK
RUN THROUGH MY LITTLE NURSERY.

THE BULB SYRINGE IS TO SUCTION
IN CASE THEY WERE TO GAG

OR YOU FELT LIKE THEY WERE
CHOKING ON SOMETHING.

AND I'LL GRAB SOME FOR
YOU. AND WE ACTUALLY --
THIS IS, KIND OF, FUNNY.

I SWITCHED THESE 2 MODULES
FOR THE FIRST TIME

BECAUSE NEXT WEEK'S MODULE
IS SO HUGE. HUGE.

IT'S OUR LAST HUGE MODULE.
AND IT'S ON RESPIRATION.

IT'S SUCTIONING AND WE
DID THAT THE WEEK BEFORE
ON SUCTIONING A BABY

AND I SHOULD HAVE PUT IT IN
WITH THIS WEEK. SO, OOPS.

WE'LL GET IT NEXT WEEK.

ALRIGHT. I'M GOING TO GO AHEAD
-- WELL, IT DOESN'T MATTER.

YOU CAN PLUG IT WITH THE
SYRINGE OR YOU CAN PLUG
THE ENDS ON THESE.

WHEN YOU PUT THESE DOWN
A BABY'S MOUTH,

YOU CAN LUBRICATE IT
WITH A LITTLE WATER,

BUT NOT WITH ANY K-Y JELLY.
THAT'S GROSS.

IT'S JUST GOING DOWN THEIR MOUTH
AND THEIR MOUTH IS WET. SO,
ON THEIR RIGHT SIDE,

AND YOU WANT THEM ON THE RIGHT
SIDE IN CASE THEY WERE TO
THROW UP OR GAG

WHEN YOU STICK THIS IN YOUR --
DOWN THEIR THROAT.

AND YOU JUST PUT THIS ALONG
THE BACK OF THEIR TONGUE IN
THE SIDE OF THEIR MOUTH.

AND THEN YOU JUST PUT IT DOWN
AND THEY'LL...

[SUCKING]

THEY'LL JUST START SUCKING
IT RIGHT ON DOWN.

AND THEN YOU STOP WHEN IT'S
RIGHT HERE AT THE TAPE.

NOW, I LIKE TO TAPE
TO THE CHEEK...IMMEDIATELY.

I MIGHT HAVE EVEN ASTERISKED IT.

BUT I WANT TO MENTION
THAT WHEN YOU TAPE,

TAPE ON THE UPPER CHEEK SO THAT
YOU HAVE MORE LENGTH OF TUBING

RATHER THAN TAPE
ON THE BOTTOM CHEEK.

AND YOU'D BE SURPRISED, HOW
MANY BOTTOM CHEEK TAPERS. OKAY.

WE NEED THE UPPER CHEEK.

NOW, WE NEED TO CHECK
FOR PLACEMENT

SO WE'RE GOING TO CONNECT
OUR BULB SYRINGE HERE AND
ASPIRATE STOMACH CONTENTS

AND SEE WHAT WE GET AS FAR
AS RESIDUAL AND TO CHECK PH.
HE DIDN'T CHECK PH,

BUT IT'S A LITTLE BIT OLDER
TAPE, SO WE CAN STILL CHECK PH.

GET ALL THE RESIDUAL THAT
YOU CAN, ALL IN ONE STEP,
PLUG IT.

IF I GOT 4 CC'S, I'M
GOING TO REMEMBER THAT.

CHECK MY PH.

MY PH IS GOOD. THEN I'M GOING
TO RETURN MY RESIDUAL.

WHATEVER. 4 CC'S.

- YOU GOT 4 [INDISTINCT].
- PARDON ME?

- 4 IS [INDISTINCT], RIGHT?
I DON'T UNDERSTAND WHY
YOU'RE TAKING.

- IF THAT'S THE CASE,
WE'LL GET THERE.

YEAH, AND THEN WE WOULD HOLD
THE PD. BUT LET'S SAY 4 CC'S.

PLUG, AND THEN WE'VE GOT
SOME CALCULATING TO DO.

SO, WE'RE GOING TO HOLD
THE FEEDING AT WHAT?

- 25%.
- 25%.

MORE THAN 25%, WHICH WOULD BE
HOW MANY CC'S OF A 10 CC FEED?

- 2.5.
- 2.5, SO WE GET TO HOLD
THE FEEDING.

RIGHT? IF OUR RESIDUAL WAS 2
CC'S, WE CAN GIVE THE FEEDING.

IF THE RESIDUAL IS 2 CC'S HOW
MANY CC'S OF FEEDING DO WE GIVE?

- 8 CC'S.
- 8 CC'S.

SO, THEY NEVER JUST KEEP LOADING
UP A STOMACH ON A BABY

WITH 4 PLUS 10 OR 2
PLUS 10 OR WHATEVER.

YOU SUBTRACT AND ALWAYS
HAVE A TOTAL ON STOMACH.

- IF YOU'RE CHECKING FOR
RESIDUAL,

WHAT'S THE POINT OF CHECKING FOR
THE GIRTH AROUND THE STOMACH?

- TO SEE IF THERE'S --
- ISN'T IT THE SAME THING?

- JUST TO SEE THEIR STATUS, TO
SEE IF THEY'RE BUILDING UP GAS,

TO SEE IF THEY'RE MOVING
FLUIDS THROUGH.

IT'S AN ASSESSMENT TECHNIQUE
TO SEE HOW DISTENSION

IS BEING RESOLVED
OR NOT RESOLVED.

HOPEFULLY, IT WILL STAY THE
SAME IF THEY'RE NOT
HAVING A PROBLEM.

BUT IF THEY'RE COLICKY AND
CRYING OR YOU'RE NOT
SEEING STOOLS,

WHAT'S HAPPENING?
IS THE GIRTH GROWING?

SO IT'S A POINT OF REFERENCE
WHEN YOU'RE DOING SOMETHING

THAT'S NOT JUST FEEDING
AND STOOLING.

ALRIGHT. WELL, LET'S SAY OURS
WAS 2, WE CAN WORK WITH TWO.

SO WE NEED TO NOW GET RID OF
2 MORE AND MAKE IT 8,

OR YOU GOT NOTHING OR WHATEVER.
YOU GET THE GIST.

OKAY. I REALLY DO WANT
YOU TO PUT WATER IN.

BUT MY BABIES WILL MOLD
IF YOU DO.

SO, WE'LL PULL IT OUT, KIND OF,
QUICKLY LIKE THAT,

SO IT'S PRETEND IN THE STOMACH.

AND THEN...

..PUT YOUR FEEDING IN.

HMMM. NOTHING'S GOING.

DON'T CHEAT AND LOOK
INTO THE BASIN.

YOU WOULDN'T HAVE A BASIN
TO LOOK INTO, RIGHT.

SO DON'T CHEAT.

SO WHAT DO YOU DO
IF IT'S NOT MOVING?

WELL, YOU GIVE IT A LITTLE PUFF.
YOU DON'T PLUNGE IT IN,

BUT YOU GOT TO BREAK
THE SEAL HERE.

AND SO JUST GIVE IT A LITTLE
PUFF AND GET IT MOVING.

OH, COME ON ALREADY.

I THINK, THERE SHE BLOWS.
OKAY.

I SAW MY FINALLY --
MY LITTLE BUBBLE WENT.
AND NOW YOU JUST HOLD IT.

AND YOU CAN ADJUST THE SPEED,
BY HOW HIGH YOU HOLD
THE LITTLE TUBE.

- WHAT'S GOING ON THERE?
THE PRESSURE IS --
THE PRESSURE IS --

- UH-HUH. BECAUSE OF THE SMALL
DIAMETER OF THIS TUBE,

SOMETIMES THE AIR DOESN'T ALLOW
THIS TO BREAK FREE.

SO YOU JUST, KIND OF,
BREAK THAT SEAL.

THERE'S PROBABLY SOME
PHYSIOLOGICAL EXPLANATION,
I DON'T KNOW WHAT IT IS.

I JUST KNOW IT IS NOT MOVING AND
I GOT TO DO SOMETHING ABOUT IT.

SO, JUST A LITTLE PUFF TO
GET THINGS ROLLING.
LET IT GO IN.

THEN YOU CAN FLUSH
WITH WHATEVER THEY SAY

BECAUSE YOU WANT THEM TO GET
ALL THEIR FEEDING, SO WHATEVER.

MAYBE 1 OR 2 CC'S OF WATER
SO THAT THEY GET ALL
OF THEIR FLUID.

OK. LET'S JUST SAY
THEY DID.

THEN WHEN IT'S ALL DONE,

YOU WANT TO TAKE THIS OFF
AND YOU WANT TO PLUG IT.

AGAIN, SO THAT YOU DON'T
GET THE MIGRATING FLUID THAT
COMES THROUGH.

TAKE IT OFF THE CHEEK AND THEN
YOU JUST PULL IT STRAIGHT
OUT OF THEIR MOUTH.

I DIDN'T MENTION MY PACIFIER.
BUT I DO WANT TO MENTION THAT

YOU NEED TO HAVE A MANUFACTURED
PACIFIER AND NOT A CREATED
FROM A NIPPLE PACIFIER.

THEY USED TO, AND HOPEFULLY
THEY DON'T ANYMORE,

PUT COTTON AND THEN JUST PUT THE
LITTLE CARDBOARD SEAL

THAT CAME WITH THE PACIFIER AND
LET THE BABY SUCK ON IT,

BECAUSE THEY DIDN'T HAVE
ANY AROUND.

WHAT THEY FOUND WAS THAT THE
BABIES WERE JUST SUCKING AIR,

BECAUSE OF A LITTLE CUT
IN THE NIPPLE.

SO, YOU DON'T WANT TO
USE A CREATED PACIFIER.

YOU WANT TO USE A REAL PACIFIER.

AND WE GET THEM FREE FROM
THE FORMULA PEOPLE.

AND SO, YOU JUST NEED TO TELL
THEM YOU NEED MORE.

ALRIGHT. ONCE YOUR BABY HAS...

..HAD THEIR FLUID, THEN
YOU WANT TO GET THEM UP

AND BURP THEM A LITTLE, HOLD
THEM, COMFORT THEM.

BURP. AND THEN PUT THEM
ON THE RIGHT SIDE.

AND THEN I LIKE TO LEAVE THE
HEAD OF THE BED UP FOR
A LITTLE WHILE.

TAKE YOUR GLOVES OFF AND
GET RID OF YOUR SUPPLIES.

TAKE YOUR GLOVES OFF, WASH YOUR
HANDS AND THEN DOCUMENT ALL THE
STUFF THAT YOU DOCUMENT.

OKAY? ALRIGHT. TESTS --