Friday, June 28, 2013

Blakemore tubes. Should an inexperienced surgeon use them?



In response to a comment mentioning Blakemore tubes on my post about what surgery was like in the 1970s, I said they were instruments of the devil.

This sparked the interest of surgeon who works in a rural hospital with minimal endoscopy services. He emailed me and asked if I thought he should have Blakemore tubes available for use because he might have to transfer a patient with bleeding esophageal varices over a long distance for definitive treatment.

He trained in the early 21st century and admitted that he did not remember ever having seen a Blakemore tube. He wondered why I didn't like it.

I have witnessed all of its major complications such as tube dislodgement, necrosis of the nose and lips, aspiration, esophageal perforation, airway occlusion and death.

Without any hands-on experience, he probably should not try to use the device. In addition, the average nurse would likely also not be familiar with caring for a patient with the tube.

On the other hand, maybe as a last resort he could try it.

I had planned to write a post about the Blakemore tube, its insertion, maintenance and complications. But while researching it, I found that others had done so, and better than I.

Read this excellent article on Medscape. Registration is required, but it is free. It covers everything you need to know about Blakemore tubes.

And here is a link to a nice video from the Yale GI service that demonstrates the steps required to safely insert and manage them.

What do you think? After reading the Medscape piece and watching the video, should this rural surgeon, who has never personally seen a Blakemore tube, use it ?

20 comments:

Sabha Ganai, MD, PhD said...

A few years ago as a resident, I placed a Blakemore tube in a last ditch effort to get control of a variceal bleed in the middle of the night. While discussing the situation with my attending, I googled to review the details on insertion... I had to laugh when I found out that my attending happened to be doing the same thing from home. It's just not common to insert, but I think it is important that they are available, especially for rural surgeons. On a side note, the first Blakemore tube we opened was made of stiff rubber that was probably 20 years old and quickly disintegrated when we took it out of the sterile packaging. We found another one that was "newer" and usable. At least bought the patient time while we got the IR team in to TIPS.

Skeptical Scalpel said...

Sabha, great comments. Thanks. I have had similar experiences. As the video pointed out, it takes time to gather all the supplies. We used to have a football helmet-like device with a pulley on it. No one could ever find it.

This may reveal my age. Once when searching for it in the hospital's basement, I stumbled across an "iron lung." You might have to google that one too.

artiger said...

I'd say that it probably doesn't hurt to have a Blakemore in a small hospital. There is certainly potential for harm in placing one, but if the result of not placing one is death, well...

I too am in a rural setting, and have limited (and distant) past experience with them. If the goal is simply to keep a patient alive for transport, I can see justification in it. Otherwise I wouldn't touch the thing.

Sabha Ganai, MD, PhD said...

Haha. We couldn't find the football helmet either but we had an awesome ICU nurse with years of experience who set up traction. It may not be as important to have an experienced surgeon as an ICU team capable enough to help you out.

Anonymous said...

Hi Skeptical Scalpel,
I really enjoy your column and have the utmost respect for surgeons such as yourself.
I'm chiming in as a nurse who vividly remembers 25 years ago working the night shift when an unstable esophageal GI bleed patient was admitted to our Medical ICU. The Chief Surgery resident came in around 2 AM and was absolutely crazed with frustration that none of us knew how to get him the equipment for the Blakemore (much less help him with the placement). We absolutely were running from the screaming Chief Surgery resident because we were so helpless and scared. The patient's nurse tried in vain to be of assistance, and the rest of us cowered in fear (I'm ashamed to admit). By some miracle the patient made it to the morning and was taken to the OR. Even after all these years, he mention of Blakemore still causes me anxiety. They are not for the faint of heart!

Skeptical Scalpel said...

Thanks for the comments, everyone. It's good to have different points of view. I'm glad I'm not the only one who remembers having problems with these tubes.

CholeraJoe said...

Since I'm the one who originally brought them up, I guess I should weigh in. When you have nothing else, they are all you've got. We used football helmets at the VA and traction at the University. Pts are easier to transport with the tube secured to the helmet's face guard. Secure the airway first. Sometimes they worked, most times the patients died anyway.

I learned to use them via the watch 1, do 1, teach 1 method. I used lots in residency. Very few thereafter. Perhaps the demographics of the patients changed.

Skeptical Scalpel said...

Joe, I believe something is different. Patients with bleeding from esophageal varices are not nearly as common as they were 30 years ago.

CholeraJoe said...

Maybe so. My 1st two months of IM residency - 1975 I treated 8 at the VA. Many were Vietnam vets and probably had Hepatitis besides alcoholism. How I stayed seronegative I'll never know. At the University Hospital in the next 2 months, I treated none. The two hospitals were next to one another.

Skeptical Scalpel said...

I can't recall that last time I treated a variceal bleeder.

Anonymous said...

I'm a surgical resident, and at a small hospital where the none of the rads people do TIPS. I've had 2 instances where the Blakemore tube was needed. One, as an intern, in a massive bleed that failed all endoscopic measures. Called in the chief resident and attending . Neither one had ever used the Blakemore tube. The GI doc was the only one available who had any experience with it (but that was once, when he was an intern some odd 30 yrs prior). We managed to find one lone Blakemore tube in a dungeon in the GI lab. Had to dust it off before use, and we all guessed our way through its placement, wikipedia on hand. It temporized the bleed, but patient never stabilized enough to transfer, and he died.

Similar situation about 2 weeks ago. While on call walked in an massive variceal bleed in the ICU- large blood puddles on the floor, blood splattered all across the walls, patients face covered in blood, while blood literally flowed out of his mouth. The GI doc had a scope down but after 2 hours had been unable to slow it down. We scoured the hospital for a Blakemore tube and couldn't find one ( I guess we'd used up the last one in stock 4 years ago). No one available to do TIPS. OR options- shunt or esophageal transection? My attending have barely had any experience with either, especially for a variceal bleed. Long story short, patient died.

So to answer your original question, I'm just a resident, but if its all you got (as in the two situations I've been in), I'd say the rural surgeon should definitely use the Blakemore tube

Skeptical Scalpel said...

Thanks for commenting. Interesting stories which help confirm that recent experience with the Blakemore tube is lacking. It's funny that every hospital seems to have one lurking in the basement.

I agree, it's worth a try if you have nothing else.

Henna said...

Interesting that in nursing school Blakemores are presented in lecture as if they are a standard intervention (speaking from my recent experience & talking to other recent grads). None of us have ever seen them used in hospitals.

Skeptical Scalpel said...

Could it be that the instructors are out of touch?

Anonymous said...

Move to NM, variceal bleeds are quite common. Especially with the high rates of alcoholism in Hispanics and Native Americans as well as IVDA (lots of Hep C).

Skeptical Scalpel said...

Are you using Blakemore tubes there?

Anonymous said...

Just throwing in my 2 cents... I work in an IR lab that had just ordered in multiple Blakemore tubes at the request of the chief radiologist. We literally only had them for a couple weeks, when we had a massive variceal bleeder come in. He had been driven in from a rural location, had spent time in Endo without success, and as last ditch effort, we went to the ICU with the Blakemore tube. We had difficulty passing the tube, as there was no stiffener or stylet. Does anyone know if any of them come with a stiffener? (Looking into it...) We had to reinforce with an angiographic catheter and wire to pass the tube. We also had trouble locating "the" helmet, as the ICU staff could not remember where it might be (PA found it in basement...).
We immediately transported the pt to IR for TIPS, and on completion of a technically successful procedure, the pt coded and passed on the table. This was as of Jan. 2015 in N. California.
It's definitely beneficial to have as a last resort. If it can stabilize a pt enough to get to a higher level of treatment, it is worth the shot.

Skeptical Scalpel said...

They don't come with stiffeners or stylets for a reason. It is very easy to injure the esophagus with a stiff tube. You did not mention whether you inflated either or both balloons and in what sequence you did it. It would have been nice if you had gotten an autopsy to see if any damage had been done.

No one ever knows where the helmet is because it is used so infrequently. Did you put a weight on the pulley or did you just tape the tube to the helmet?

I hope you read and saved the links in my post about how to insert and care for a Blakemore tube.

Anonymous said...

I apologize in advance for hi-jacking a medical blog but my step-dad is laying in the hospital bed just having had his Blakemore removed...the procedure saved his life. Thank goodness the doctor in the ER we went to knew about the procedure and performed it and are grateful the hospital had a football helmet on hand.

Skeptical Scalpel said...

No apology necessary. I'm glad he's OK. You were indeed lucky to have gone to a hospital with a doctor who was familiar with the use of the Blakemore tube. Best wishes to your step-father.

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