What the heck are all those tubes anyway?
written by Suzanne Bickerstaffe, RN, CRNI
The XFiles has any number of scenes set in the ICU, most of them extremely authentically done. But aside from Critical Care nurses and physicians, not many viewers understand all the lines and tubes and their various functions (then again, some don't WANT to, which is also understandable). The following is a head to toe analysis of an unfortunate patient (commonly known in ICU parlance as a "train wreck") who has all the tubes medical science has to offer, and an explanation of the purpose for each.
This is the tube inserted into a nostril, and taped onto the nose to hold it in place (Mulder in "End Game", Skinner in "Apocrypha"). This flexible plastic tube, inserted by a nurse or doctor, goes into the nose, down the throat and esophagus, and into the stomach. It has numerous functions, depending on the patient's condition. The first is to keep the stomach empty. In poisonings, this tube is attached to a large syringe, and the stomach contents, including the poison, are manually sucked out (see Poisons section, re "stomach pumps"). In injuries to the stomach or intestinal tract, it is attached to low suction and keeps the stomach empty of acids and bile, reduces nausea, and rests the digestive system. In stomach bleeds (gunshots, perforated peptic ulcers) it removes the blood and serves as a vehicle for ice water gavage (inserting ice water through the NG tube, into the stomach and then withdrawing it, helping to stop the bleeding). The NG tube can also be used for giving medications or formula feedings to patients who cannot swallow or are unconscious.
The (usually) pale green tubing with little prongs inserted into the nostrils (Mulder, at one point, in "Beyond the Sea"). This is the most common way of giving oxygen. In more severe cases of shock or oxygen shortage, it is given by mask (Mulder at the ER in "Beyond the Sea"), or by...
The tube is inserted through the mouth, down the throat, down through the trachea and into the bronchus (Mulder in "End Game", Scully in "One Breath", Mom Mulder in "Herrenvolk"). The main purpose of intubating patients is to connect them to a ventilator (AKA respirator) when they are unable to breathe adequately (or at all) on their own. Generally an anesthesiologist or a specially trained Respiratory Therapist performs the intubation. The tube is then connected to a ventilator, which is set to deliver a certain number of breaths per minutes with a specific volume of oxygen. This tube is taped VERY securely (excellently portrayed in "One Breath" and "End Game", not well done in "Herrenvolk"). Not shown in any of these episodes is the fact that the wrists of intubated patients are always securely restrained. The tube is very irritating, and the first act of anyone on regaining a certain level of consciousness is to reach for the ET tube to try to pull it out. These extubations can be traumatic (the ET tube is also held in place internally by an inflated balloon-like collar), and regardless of the state of consciousness, the patient may be dependent on the ventilator for adequate breathing. So the restraints are necessary to prevent inadvertant extubation.
The patient can be removed from the vent for a few seconds at a time. This allows the nurse or respiratory therapist to use another catheter or tube to suction out secretions in the ET tube. This is generally done every couple of hours or as needed.
Usually as patients become more able to breathe on their own, they "fight the vent". When this happens, the patient is restless, coughing or gagging, tries to breathe at intervals other than those set on the ventilator, and triggers all kinds of alarms. The patient is then given a "trial" - he remains intubated, but is disconnected from the vent, breathing oxygen from the tube. Blood gas studies are then done to determine how effective the patient's breathing is (see "Arterial Lines", below). If it is effective, the inflatable internal collar is deflated, the tape is removed and the ET tube is pulled out. The patient usually has an extremely sore throat, due to irritation of the tissues by the tube. Mulder's croaking speech in "End Game" was lovely touch of realism. If the patient fails the trial, he is reconnected to the vent, and often given medications (pain meds, tranquillizers, and even meds to temporarily paralyse the muscles of respiration) so that he will not fight the vent, will be more comfortable and the ventilator can do its job. Further trials are performed when the patient is conscious and once more trying to breath on his own (also called trying to "wean" the patient from the vent). If the patient must remain intubated for an extended period of time, the ET tube is replaced with a ....
A "trach" is a permanent or long-term passage made by inserting a curved tube through an incision in the patient's neck and trachea. An inner cannula is inserted through the curved tube, fastened and connected to a ventilator, or possibly just an oxygen mask if the patient can breathe on is own. The ET tube is replaced because it causes friction on the delicate tissues of the mouth and throat which over time can cause necrosis (death of the tissue - a complication to be avoided). Generally this is not a problem unless the patient has been intubated for more than a week or two.
These have been covered to some extent in the section on Shock IV lines can be peripheral (inserted by a nurse in the hands, arms or rarely, the feet) or central (inserted by a physician, usually a surgeon, into major vessels in the neck or chest.) Long term IV lines (in place for more than a few days) or lines for very sick or seriously injured patients are usually centrally placed. There are several reasons for this. First, peripheral lines need to have their placement changed every few days, which is traumatic for the patient and increasingly difficult for the nurse, as the number of healthy, non- punctured veins becomes extremely limited after a couple days of blood draws and IV therapy. Also, peripheral lines can infiltrate - the needle or plastic cannula moves out of the vein and into the surrounding tissues, causing swelling and other, possibly more serious complications.
On the other hand, central lines don't infiltrate, their placement doesn't have to be changed, and they are inserted into major vessels capable of handling large amounts of different kinds of fluids. Central lines often have multiple lumens - color coded plastic lines with ports where the fluids can be plugged in. One lumen may be used only for blood transfusions, while another is used for medications, and another is used for TPN (Total Parenteral Nutrition - a high fat, high calorie kind of IV feeding). Thus one central line is fulfilling the function of several peripheral IV lines. Further, certain fluids - like TPN and some sorts of cancer chemotherapy and antibiotics - can be given only by central line because they are too irritating to the vein to be given peripherally. Sometimes a patient may have both kinds of lines. It's certainly not unusual for a seriously injured patient (Mulder in "Beyond the Sea" for example) to be receiving blood transfusions through one or two lines, fluids through one or two lines and medications through another IV line or two. IV lines are never all removed until the patient is capable of taking in sufficient food, fluids and medications by mouth.
Rather than a line for delivering fluids, a Swan- Ganz is a delicate measuring instrument. It's a plastic line that looks something like an IV line and follows the same pathway as a central line (inserted through the internal jugular vein in the neck or the subclavian vein in the chest/shoulder),and then the instrument is carefully threaded into the chambers of the heart itself. The Swan-Ganz measures fluid balance and various pressures, with the readouts appearing on one of the monitor screens over the bed. They also, with the addition of another instrument, have the ability to measure core temperatures (see section on Vital Signs -Temperature ) and cardiac outputs. Generally speaking, only the most ill and medically compromised patients have these.
All patients in the ICU have cardiac monitors, which display the heartbeat graphically, allowing the nurse to see abnormal rhythms, and give a constant readout of the pulse rate. The patient is connected to the monitor by means of (usually) 3 to (rarely)12 wires. These wires are snapped on to little sticky pads placed at particular intervals around the patient's chest, then the other end of the wires are snapped into a single connector cord which goes to the monitor. Like all the other monitors and pumps in the ICU, cardiac monitors have alarms which ring if the patient's rates fall outside individually set parameters.
An A-line is is a clear line that looks a lot like an IV line, but has valves and stopcocks. (When the nurse draws the blood sample that gets stolen in "One Breath", there is an excellent closeup of a realistic-looking A-line). A-lines are connected to bags of fluid, but these bags are placed in pressurized sleeves. The A-line is never used to deliver fluids - the pressure of the arterial blood flow would make it impossible. Rather, the arterial line, usually inserted by a physician into the radial artery in the wrist, has two main functions.
First, it is used to provide a constant readout of the patient's blood pressure, which appears on one of the monitors over the patient's bed. For medically unstable patients, this is extremely important.
The second function is to provide easy, painless access to obtain blood for labwork. It's not unusual for ICU patients to have labwork drawn six or more times a day, plus arterial blood gases drawn at least twice a day. The A-line prevents the patient from having to be stuck every time. A device is placed into a port on the A-line, the lab tube attached, a stopcock is turned, and blood fills the tube. Tubes can be put on and taken off without the patient bleeding (different tubes are used for different kinds of lab tests). When all the blood necessary has been drawn, the nurse turns the stopcock to another position and flushes the line, so that blood doesn't clot in it, blocking it off and making it useless. When the line is clear of signs of blood, the stopcock is returned to its original position and the blood pressure readout returns to the monitor.
Drains are tubes that are attached to small plastic or rubber reservoirs that remove blood and other fluids that would otherwise collect internally. Drains can be found anywhere - coming from the brain, a joint, a surgical site, the abdomen. Some drains have special names, depending on their design and purpose, such as a Jackson-Pratt drain (J-P) or a T-tube, but basically all have the same purpose. The reservoirs of the drains are emptied and the collected fluid (usually blood, serous fluid, lymph or bile) measured at set intervals. When there is almost no fluid coming out, the drain is pulled out.
A G-tube is a fairly large sized (0.75 - 1 cm) rubber tube placed directly into the patient's stomach via a tiny incision made through the abdominal wall and the stomach. This tube fulfills the same function as an NG tube, but is used where an NG tube would be inappropriate (severe facial or throat injuries/deformities) or, more commonly, when the tube must be in place for longer than a week or two (with the same rationale as removing an ET tube for a trach). The G-tube is usually used for long-term or permanent feeding of a patient who cannot take food by mouth. A nutritional formula is funnelled into the tube several times a day, or there are continuous feedings delivered by a feeding pump (which looks a lot like an IV pump). Conditions necessitating a G-tube would include dysphagia (inability or difficulty swallowing), coma, or damage to the mouth, throat or esophagus.
This is a very thin plastic tube also used for long-term feeding of patients who, in addition to the above conditions, have damage which prevents food from being delivered directly into the stomach. The J-tube is placed through the abdominal wall into the jejeunum, a part of the small intestine.
A Foley catheter is a soft, flexible rubber or silicone tube inserted into the bladder (it sounds worse than it feels) for the purpose of draining urine. Even though every unconscious, intubated or ICU patient has one, don't look for any examples of Foleys in The XFiles. Apparently it is the one kind of tube they draw the line at showing. The drainage of the urine is involuntary - as it is produced by the kidneys and empties into the bladder, it is drained down the catheter through some clear tubing into a collection bag. The collection bags for the most seriously ill patients have an attachment called a urimeter. This device collects and accurately measures the urine. Recordings called Intake and Output (I&O) are made hourly of all the fluid the patient has taken in (by mouth, IV's, blood transfusions, etc.) and has put out (urine, bleeding, NG tube and other tube drainage). These numbers are watched carefully. Urine output is an important measure of organ perfusion, fluid balance and kidney function, and the Foley catheter makes its accurate measurement possible.
Some conditions inhibit the bladder's ability to release urine. In these cases, the catheter prevents the bladder from becoming overdistended and indeed from rupturing. In other conditions, such as coma, there would be no bladder control at all. The Foley prevents the patient from being incontinent of urine, which would not only make measurement difficult, but also would have serious effects on the patient's skin. The catheter also makes it possible to acquire urine specimens whenever needed for laboratory testing (done one or more times daily).
A couple of final words about life in the ICU.
Siderails are ALWAYS in the UP position on EVERY patient's bed or stretcher, unless a caregiver is standing at the bedside. Even then, they often remain up unless they are actually interfering with giving care. This is one of the strictest rules in any hospital, although it's the one you are least likely to see on any TV show, even the otherwise authentic hospital scenes in The XFiles.
Along the same lines, patients are not usually positioned on their backs, and certainly not for days at a time (Scully in "One Breath"). Especialy in ICU, patients are turned at least every two hours, usually from side to side. A patient left on his or her back for several hours would develop bedsores (also known as decubitus ulcers) from pressure and from decreased circulation. Patients who are not turned regularly are also at high risk for developing pneumonia (see Brok en Ribs section) and for blood clots in the legs due to impaired circulation.