Orifices: The ins and outs of the body
Foley catheters, rectal tubes and ostomies are an EMS issue
It is obvious that we are facing a dramatic increase in health care needs due to an exploding population that is rapidly aging, served by inadequate numbers of physicians, mid-level providers and nurses, and burdened with spiraling healthcare costs.
So who do you think might be tagged to help take up some of the slack? EMS represents a huge healthcare resource and it cannot remain just for emergencies anymore. Although many countries have expanded roles for EMS, we are beginning to explore our capacity to provide a greater scope of care.
With that, let me introduce you to the world of temporary and not so temporary manmade body cavity access devices and procedures that may require your current or future patient care expertise.
There are seven natural body openings or orifices providing access to an internal cavity through a natural passage called a canal, duct or meatus. So, from the top of the body down:
External auditory canal or meatus directs air waves from the outside to the tympanic membrane converting mechanical energy to electrical energy in the internal auditory canal or meatus that is sent to your brain.
Nares are the entrance to the nose and the slimy surface inside that collects dust, pollen, etc. to keep it out of your airways and helps warm the outside air before it hits your lungs.
Nasal meati are openings inside the nose leading to the four paired sinus cavities that also collect inhaled particles, warms the air and also lightens the weight of your skull, which gives some truth to the term “air head."
Mouth provides access to the gastrointestinal tract and the respiratory system
Urethral meatus transports urine from your bladder to the outside
Anus for solid waste output
Vagina, the conduit to the uterus from whence we all came to being
The sphincter is a circular muscle surrounding a natural body opening or conduit. They range from very small as the thousands of capillary sphincters that open and close the smallest blood vessels, to large sphincters that manage higher flow volumes such as through the esophagus or out the anus.
The importance and intelligence of the sphincter is not to be taken for granted. This can be demonstrated by a thought experiment. Imagine your hands are cupped together and filled with water, sand and air; could you open your hands and allow only the air to escape? The anal sphincter does that routinely.
Temporary interventions following normal anatomic pathways
Nasogastric and orogastric tubes provide temporary access to the stomach for suction of contents or irrigation (lavage) or to administer medication or nutrition (gavage). These tubes are uncomfortable and careful manipulation will minimize discomfort.
The opening to the esophagus is close to the opening to the lungs (larynx), thus a displaced gastric tube is an aspiration risk. Tube placement is confirmed by X-ray and the distance of insertion is noted or marked to monitor any tube drift.
Intubation of the trachea can be accomplished via the nose or the mouth and is a familiar out-of-hospital intervention with potential problems of misplacement and displacement.
Urinary catheters are flexible, smooth tubes that can be inserted for a quick in and out procedure to obtain urine for testing. They can also be left in place for continuous drainage as an indwelling (residing inside the body) catheter.
Years ago Dr. Frederic Eugene Basil Foley developed the first flexible indwelling catheter with an inflatable balloon on one end to keep part of the tube inside the bladder. The Foley catheter is both friend and foe as it provides a portal for bacteria to enter the bladder and blood stream thus increasing the incidence of urinary tract infections, sepsis and patient deaths.
We worsen the chances of such infections by inserting them too often and waiting too long to remove them, simply for our convenience as caretakers.
Rectal tubes are obviously inserted into the rectum and can be used to introduce a variety of liquids to relieve constipation or to deliver medication such as lactulose that absorbs excess ammonia produced by the liver failure patient or kayexalate to help decrease high serum potassium levels though binding with potassium which is then excreted in the stool.
Some rectal tubes look like large Foley catheters as they have a balloon on one end to anchor the tube in the rectum. This may be useful when a patient has temporarily lost voluntary control of the anal sphincter. Continuous stooling can cause skin breakdown and prevent local wound healing.