Luckily this isn’t a procedure you will have to do very often. At its most basic level, it’s pretty simple: balloon in the stomach, balloon in the esophagus, suction port in the stomach. However, the devil is in the details. Here are two good videos of how to do the procedure, but neither one by itself is how I would do it in our ED. Watch these videos, and I’ll tell you my thoughts.

Dr. Jess Mason’s version:

Dr. Scott Weingart’s version:

My thoughts about how it might work best at our hospital:

Unfortunately, the Blakemore tubes that we have don’t come in a kit with the accessories. As you can see in the videos, people have their own setups and ‘make it work.’

Stopcocks vs Christmas trees: In Dr. Mason’s version, she plugs stopcocks into the esophageal and gastric lumens and says that they should fit snuggly. We have the same Blakemore tube and what appears to be the same thee-way stopcocks, but they leak when I’ve tried to connect them the way she shows it done.

If I had my choice, I’d use the Christmas tree adapter like Dr. Weingart suggests as I think that would be a more reliable seal. (He refers to them as “christmas trees” – a term often used in reference to the green adapters that allow oxygen tubing to connect to the wall spicket. Perhaps a more precise term would be “luer tip catheter adapter” although there truly is a product called a Christmas tree adapter that would work as well.) Whichever you choose, realize this is an improvised solution as some references (i.e. the current version of Roberts and Hedges’) don’t mention stop cocks at all, but rather clamping with “tube clamps,” which are something I don’t recall having ever seen in our department. I assume I could improvise with some hemostats and tape, but in our shop these patients get transferred and I’ve been guilty of transferring patients out with tools that we would prefer to have kept. Disposable or single use is better in the case of a transfer.

The manometer: I think the one Dr. Mason recommends is slicker, and indeed we do have one that the respiratory therapists keep in cardiopulmonary – just like she said we would.

Although Dr. Weingart’s would work, it has more moving parts and thus more ways for me to mess it up. I worry that in a pinch, when someone is bleeding out in front of your eyes, people would forget both: that we have one and where it is and also the somewhat laborious process of setting up the handheld blood pressure cuff. Perhaps the simplest thing would be to remember that its probably around 50 – 70 ml of air that would get you to about 30 cc H₂0 in the esophageal balloon. Almost every reference has a slightly different way of dealing with this issue. Some use Y-connectors and suction tubing. Some use a stopcock called a Lopez valve, which has 1 or 2 tubing connectors and a luer lock rather than 3 luer locks. It gets confusing in a hurry if you haven’t thought through what will work for you in advance.

The NG-tube with markings on it: This is brilliant. I forget this every single time. These are very stressful procedures and subtlety and nuance are difficult in those cases. I feel that more of ‘damage control’ approach is okay, and if I can get anything in and the bleeding slowed, it’s a win. Of note, this esophageal suction port is what a Minnesota tube has that a Blakemore does not. So, this is sort of a way to Macgyver a Minnesota tube out of a Blakemore tube. I worry this makes things unnecessarily complicated, but what do I know?

How to get the tube to go down: I feel like both of these videos gloss over how difficult it can be get the tube to go down the esophagus of an intubated person. The instructions that come with the tube imply that you have them swallow, like an NGT. But, in my experience by the time you get to a Blakemore tube, these patients often need their airways managed. We keep our tubes in the freezer, which gives them a little bit of stiffness – temporarily. I’ve also put a bougie in the most distal side port, which has worked great – but you do have to make sure not to tuck it into that side port too tightly or you’ll just pull the the tube out when you pull the bougie. A laryngoscope, either direct or video would likely help you guide the tube into the esophagus, but it can feel like pushing a spaghetti noodle.