Nasogastric tube insertion and position checks
PLAB 2 & PRES 3 · practical skills / surgery · medium · 8 minutes
Candidate brief
You are an FY2 doctor on a surgical ward. Mr George Whitaker, 70, is two days post laparotomy and has developed a post-operative ileus with profuse vomiting. The surgical team has asked for a nasogastric tube on free drainage to decompress his stomach. He is nil by mouth. A manikin is provided for the insertion. The patient is present: explain the procedure and gain his consent, then insert the tube on the manikin and confirm its position, verbalising each step and check as you go.
What examiners look for
Position confirmation is the station. Insertion is the easy half; the marks — and the patient's safety — sit in the checks: aspirate with pH 5.5 or below on proper pH indicator paper, or a correctly interpreted X-ray. Everything else is technique; this is judgement. The whoosh test is banned for a reason: air injected into a tube sitting in the lung can produce sounds transmitted to the epigastrium that sound exactly like a stomach. It has featured in fatal incidents, and examiners treat its use as a serious error, not an old-fashioned quirk. An NG tube in the lung that gets used is a Never Event. The corollary is a behaviour, not a fact: the tube is not used — for feed, medication, or even charted drainage — until confirmation is documented. "Probably in" is not a position. NEX is measured, not estimated: nose to earlobe to xiphisternum, marked before insertion. Tubes inserted to a guessed depth are the ones coiled in the oesophagus or short of the stomach. Confirmation is not a one-off event. Vomiting, retching and coughing — this patient's exact symptoms — dislodge tubes. The check repeats after such episodes and before each use; a tube confirmed on Tuesday is an assumption on Wednesday. Stop rules protect the airway: coughing, breathlessness, inability to speak or falling saturations during insertion means the tube is heading for the lung — withdraw, let the patient recover, reassess. Pride has no role in NG insertion.
Guideline references
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