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AMERICAN JOURNAL OF EMERGENCY MEDICINE n Volume 10, Number 6 n November

1992

of National Health and Welfare, Health Protection Branch, for their consideration. Readers are urged to examine wall outlets in their institution and to institute appropriate educational and awareness programs. The author thanks Viola Norwood aration of this report.

for her assistance

ISSER DUBINSKY.

in the prep-

BSc, MD

North York General Hospital University of Toronto Toronto. Onturio. Canudu

References

FIGURE 1. cle.

Photo of wall outlet for medical gases in patient cubi-

treated with salbutamol and ipatropium bromide by mask. nitroglycerine paste, and diltiazem. as well as her other regular medications. Despite therapy, she continued to complain of shortness of breath. Orders were given to place her on a venturi mask with an FIO, of 30% and medical consultation requested. Admission was ordered. but owing to the unavailability of an inpatient bed, the patient was kept in the emergency department overnight in the examining cubicle in which she initially had been examined and treated. Therapy continued overnight, but the patient continued to complain of dyspnea and orthopnea. Her Fro2 was adjusted on the venturi mask to 35% and subsequently, to 40%. Despite this, the patient continued to complain of shortness of breath and was treated with morphine and ativan on one occasion. Repeat arterial blood gas determinations done after the Ftoz was increased to 35% and again to 40% showed essentially no change from the initial determination. After the third blood gas result returned, the suspicion of a defect in the gas delivery system arose. Careful scrutiny revealed that the oxygen tubing was indeed attached to the medical air outlet. not the oxygen source. The oxygen tubing was subsequently attached to the appropriate flowmeter and the patient’s symptoms improved. Repeat arterial blood gas determinations done on oxygen showed improvement in PO,. The subsequent course in the hospital was uneventful. This patient was one of the first treated in a newly renovated department. An integral part of the renovation/addition project was the installation of new oxygen, suction, and medical air lines and systems. It was quickly recognized that although the oxygen and medical air systems were labeled, the flowmeters were indistinguishable, and that the oxygen tubing readily tit onto either outlet (Figure 1). This concern was rapidly confirmed by our unfortunate experience with one of the first patients treated in the new facility. Inquiries were launched into the availability of “color-coded” flowmeters to avoid such errors in the future. Unfortunately. none are currently available. As a consequence of this experience. all the air flowmeters in our department have been removed and are reconnected on a patient-specific basis only. Other specialties (eg, anesthesia) already have recognized the potential of inappropriate hook-up to gas delivery systems and have responded with systems of pin indexing and color coding of tanks and delivery lines (eg, oxygen, white; nitrous oxide, blue; air, grey and black stripes). While complications in this patient were fortunately minimal, there is a clear potential for catastrophe. Alternatives to avoid such disaster include color coding of flowmeters to universal standards (eg, white for oxygen, grey-black stripes for medical air), colortreated gas tubing. or the creation of “gas-specific” connectors that link tubing to flowmeters. In the interim, this report has been forwarded to the Department

1. Pilot tube’s resemblance to feeding tube connector cause of near fatal accident. Biomed Saf Stand 1987;1:51

is

2. Katz L, Crosby JW: Accidental misconnections to endotracheal and tracheostemy tubes. Can Med Assoc J 1986;135:1149-1151 3. Hazards of Medical Device Connectors (Medical Devices Alert). Ottawa, Canada, Health Protection Branch, Department of National Health and Welfare, July 1987, pp 13-15 4. Dubinsky I: Near death caused by accidental misconnection to an endotracheal tube. Can Med Assoc J 1987:137:1105-l 106

AVOIOING NEEDLE-STICK INJURIES IN THE EMERGENCY DEPARTMENT To the Editor:-In the ongoing effort to avoid needle-stick injuries in the emergency department. Dr Renschler’ recommended one solution to the problem. He suggests installing disposable needle containers on all gurneys. mounted right underneath the patient on both sides and at the head of the gurney. Unfortunately. this suggestion has a major drawback with both medical and medicolegal implications. We have had the unfortunate experience of children. both our patients and their offspring, playing with needle boxes within their reach. In one case a child put her hand into a needle box and was stuck with a contaminated needle even though the container was designed to prevent such an occurrance. We have since heard of other emergency departments being cited for having needle disposal containers within a child’s reach. Having these containers conveniently placed near the bedside is an important health care and preventive health measure. Nevertheless, mounting disposal containers on all gurneys can be dangerous unless they are mounted clearly beyond the reach of children. HOWARD A. FREED,

MD

Albany Medicul College Albany. NY

Reference 1. Renschler MF: Avoiding needle-stick injuries in the emergency department. Am J Emerg Med 1992;10:267-268 (letter)

A MODIFIED METHOD TO INSERT A NASOGASTRIC TUBE WITHOUT KINKING IN THE NASAL CAVITY To the Editor:-The nasogastric (NG) tube is commonly used in many situations such as upper gastrointestinal bleeding, head injury, and some operative procedures. Insertion of the NG tube is quite easy in the majority of patients, but there is some difficulty in inserting the NC tube when the patient is unconscious or anesthetized without swallowing capability because it often kinks in the oropharynx or nasopharynx. If the NG tube passes through the nasal cavity into the oropharynx in the unconscious patient, the medical staff. using fingers or instruments, can guide the NG into the esophagus without kinking in the oral cavity.