VentMedic Posted March 3, 2008 Share Posted March 3, 2008 I have done many of these in fact I suspect more than most MD (even those practicing in ICUs) Are you referring to your RT days? I just had a guy admitted with a Montgomery trach that can not remember the model number of his trach. His device has a 9 mm connector instead of 15 mm. Did you know the Montgomery brand has over 150 devices? Those are always fun to find in the field just like the Jackson Silver or Stainless. The text books made an over generalization when they stated every airway device is 15 mm. Do you see why I am countering with these points , we are all shooting in the dark with this senario, simple. I don't like scenarios on the forums because they are mostly guessing games or trying to fit the patient into a diagnosis with one or two general symptoms and a set of vitals. It would be nice if all patients only had one or two well known disease processes that were so obvious. Link to comment Share on other sites More sharing options...
Scaramedic Posted March 3, 2008 Share Posted March 3, 2008 ...whats an ALF... [align=center:263e8e37ef][/align:263e8e37ef] [align=center:263e8e37ef]Alien Life Form[/align:263e8e37ef] Oh come on, I bet I wasn't the only one who thought about the little fuzzball when they read this scenario!!! To bad the dad from the show is now a meth addict. I agree with 'Zilla, first thing grab one of those little pink 5cc's of NS, squirt it down the trach and suction. I've seen some amazing turn arounds on such a simple thing. Sorry RT's if that's wrong I am not fully functional in the magic surrounding the 150 different types of trachs. :shock: Just a side note years ago we had a case of those shipped in winter. Somewhere along the line they were exposed to the cold air. When we opened the box they were frozen solid and most had cracked open. Link to comment Share on other sites More sharing options...
tniuqs Posted March 3, 2008 Share Posted March 3, 2008 Are you referring to your RT days? Yup not a lot of stat trach changes in the field these days ... remote stuff, really remote. Never seen one, may be in a text book but would sure be a shocker to find with 9 mm. :shock: I had an old silver one, Korean War Era, the type one changes the cuff on. I melted it down for the silver, because in a previous life I was a Pirate... har har. Ditto. :roll: Link to comment Share on other sites More sharing options...
AMESEMT Posted March 4, 2008 Share Posted March 4, 2008 tniuqs = I don't think Doczilla is saying to go out of your scope of practice. Seeing as the vast majority of the individuals responding to the scenario are from the US, it is in the paramedic scope of practice, he is saying what to do in general. If it is something you can't do in your scope of practice then ignore it and follow what is in your scope. shannon710 Did removing pt from the vent and bagging, suctioning, replacement of the trach. (or insertion of ETT) solve the airway and breathing problems? Link to comment Share on other sites More sharing options...
VentMedic Posted March 4, 2008 Share Posted March 4, 2008 tniuqs = I don't think Doczilla is saying to go out of your scope of practice. Seeing as the vast majority of the individuals responding to the scenario are from the US, it is in the paramedic scope of practice, he is saying what to do in general. If it is something you can't do in your scope of practice then ignore it and follow what is in your scope. How many trachs have you changed? Where did you get your training for the many different trachs in patients? Are you familiar with all the disease processes and anatomical malformations that require a trach? People shouldn't be pulling out devices needlessly when some have not even had the training to correctly identify or assess the device in someone's throat. Some of these devices require an OR visit to change. If there is a narrowing above or below the stoma or the stoma closes when the trach is removed, you had better have an immediate way to dilate it or even a neonatal tube may not pass. If you make a false track on the first pass, any repeated attempts will follow that false trach even on cannulation attempts with an ETT. If the patient has a disease like Wegener's, the bleeding will be difficult to control. Making a general statement to imply that it is no big deal is not appropriate in all circumstances. To also imply that an RN change the trach with only a BLS crew there knowing that there may not be an EMT-P or RRT around to do another advanced airway procedure such as ETI is not acceptable either. Ignorance is not bliss when you may be screwing around with someone's only airway option. Link to comment Share on other sites More sharing options...
tniuqs Posted March 4, 2008 Share Posted March 4, 2008 tniuqs = I don't think Doczilla is saying to go out of your scope of practice. Seeing as the vast majority of the individuals responding to the scenario are from the US, it is in the paramedic scope of practice, he is saying what to do in general. If it is something you can't do in your scope of practice then ignore it and follow what is in your scope. As a card carrying active registry as an RRT (better yet excessively overpaying registration and membership dues) One I believe, can be there own judge in this decanulation of trach "emergent" senario, Ventmedic has posed a volume of good advice on this topic and I believe it has become a very good venue in this area for discussion, both the aggressive pro, and conseravative con. Just personally we are DANG lucky that we have her trapped in EMT CITY .... lol. Point being with all these valuable excange of ideas, one must ask oneself "should I do no harm ?" as in most cases the REMP-P "even if it states in protocol, guidelines, or even legislated should one arbitrarily yank this airway, this is a true specialty area and should be highly respected, as is ventmedics astute advice and her well spent time in posting ALL this good advice. On average the RRT programs are degree level (not associate) but Bachelors degrees, minimum of 2 years and a bit of a grinder and oddly enough one thing they (RRT) have in common is national registrys, national and some international reciprocity .... factually. Funny thing is that on my old ICU unit the ER MD does do a rotation, yet under NO circumstances are the R 4/5/6 even allowed to touch the VENTS, (or take serious risk of drawing back the bleeding stumps of fingers on my old unit) heck or even allowed do trach changes ... even electively. Bottom line what am I suggesting is if you don't FULLY understand that widgit/have training/or experiance in this area, no brainer dude SIMPLy fall back on to what the Paramedic does/knows best and is an expert in ... the ETT. shannon710 Did removing pt from the vent and bagging, suctioning, replacement of the trach. (or insertion of ETT) solve the airway and breathing problems? I too would invite shannon back to have more input regarding her patient as it could be fun to continue this senario, but I think we scared her off ? I sure hope not ! cheers Link to comment Share on other sites More sharing options...
AMESEMT Posted March 4, 2008 Share Posted March 4, 2008 Vent = easy there. No I have not changed any trachs yet, seeing as I am in medic school and as a basic I would not feel comfortable doing that even if I could. Also, yes there are quite a variety of brands of trachs and I was taught that if you don't know how to use it ask. The caregiver usually has more knowledge on that technology than the Paramedic and we should not be afraid to ask...I am not afraid to ask if I am not sure about it. Even better, I would have the caregiver change it instead of me since they have done it more times that I have. You refer to anatomy...I have some knowledge about it seeing has I have had a family member with one. Each person is different so things can be a little different. I don't claim to know all. Did I say to needlessly pull it out or have it changed without someone who can do an advanced airway present? Nope. Each situation is different. If you can't ventilate through the trach after suctioning, common sense would be to try something different (e.g. cover the trach and try the BVM, or removing the trach, etc.). Yes false cannulation can happen, but if you use a bugie (sp?) or flexible suction cather as a guide through the old one the chances of false cannulation are decreased because you have that guide. I guess a few misunderstood what I was saying. If someone posts something to do as a suggestion and it falls outside of your scope, then don't do it, follow what you are allowed to do and use common sense. Seeing that there is a variety on where people come from we have to take into account that you need to just follow your protocols and common sense when using them. Ames Link to comment Share on other sites More sharing options...
tniuqs Posted March 4, 2008 Share Posted March 4, 2008 [ I would have the caregiver change it instead of me since they have done it more times that I have. Did you read the logical approach presented before? Just why would EMS be summoned if caregiver was @ bedside that was experianced enough to do an exchange, cart comes after the horse. You refer to anatomy...I have some knowledge about it seeing has I have had a family member with one. Each person is different so things can be a little different. I don't claim to know all. First off, sorry not good to hear about a loved one with a tube and your correctamundo! "No one knows it All" but the more you learn, the more you find out how much you really don't know. The more I learn the more questions I have to ask, and some so stupid i embaress myself ps (thats why a wear a mask) tee hee. Each situation is different. If you can't ventilate through the trach after suctioning, common sense would be to try something different (e.g. cover the trach and try the BVM, or removing the trach, etc.). Yes false cannulation can happen, but if you use a bugie (sp?) or flexible suction cather as a guide through the old one the chances of false cannulation are decreased because you have that guide. Damn I am so happy that someone else can't spell bougie MAN it took me 3 years to get that right! Ok an idea but in a pinch, but just about all Trach's have an inner obturator, there is reason for this, just look at the bedside back/up that you have with your family member, look at the distal end please. I guess a few misunderstood what I was saying. If someone posts something to do as a suggestion and it falls outside of your scope, then don't do it, follow what you are allowed to do and use common sense. Seeing that there is a variety on where people come from we have to take into account that you need to just follow your protocols and common sense when using them. Look back to ventmedics first post, GREAT Teaching INFO ! OK I CALL ! Put the cards on the table: (politely) can anyone in EMT city post a trach exchange protocol/ procedure/policy in their company/state/provincial cook books for EMS applications re: Trach exchanges ... I so could use a copy for my Guidelines. cheers Link to comment Share on other sites More sharing options...
VentMedic Posted March 4, 2008 Share Posted March 4, 2008 AMESEMT, apologies if I offended you. I also lumped in other comments made in earlier posts. I realized my limitations when I was "just a Paramedic" and fell in love with respiratory gadgets many years ago. If one can easily pass a suction catheter and the inner cannula is clear, the ventilation problem does not lie with the trach but rather the patient. Often, the "resistance" inexperience people feel is the carina. For an adult, if the suction catheter is in the length of an adult's middle finger plus the knuckle (length of 15 mm adapter) then you are probably through the end of the tube. For kids, use the length of their middle finger and knuckle. Do an air flow assessment which will tell you if the trach is false trached which can happen if the trach ties are too loose. If there is NO air movement, resistance is met at the end of the trach, inner cannula is clear and the patient can speak with out a speaking valve, the trach is probably false tracked. They can be a b**** to get back in track. If the person can still up their upper airway, take advantage of that. This person would probably do okay with out the trach in their throat since it is in the wrong track. If they are still ventilating and oxygenating adequately I would not try to re-track the trach so not to make the false trach larger. Even the ED and Pulmonary doctors will call the ENT doc for these. I do get annoyed when EMTs and Paramedics pick up "trach" patients from NHs and home for many reasons and never examine the "trach". They assume it is a "trach" like the one in the Paramedic/EMT textbooks. They assume they can just ventilate through that if the patient gets into trouble. Things I have seen and some tips: Shiley trachs have a removable inner cannula which is also the 15 mm adapter. Many patients don't like it because it unclips easily and can be coughed out. So, they don't always use the inner cannula if they are not on a ventilator. Some home care companies may send them the wrong inner cannula if any at all also. Jackson Silver and Stainless steel trachs don't always come with a 15 mm adapter. To remedy this in an emergency, just put the 15 mm adaptor from an ETT into the trach. Many in home care may be smaller (#4 Shiley or Jackson and #6 Portex) which can take a 4.0 or 4.5 ETT 15 mm adaptor. The Montgomery devices can be more difficult like the 9 mm in one of my patients. I can use 4.0 ETT inside the device or a 10.0 ETT on the outside. We also save our 15 mm adapters from expired and opened but not used ETTs for these patients. A trach can also have a cuff and be fenestrated. If air is coming up through the throat with the cuff inflated, look for an inner cannula to block the fenestrations. It shouldn't take much air to fill a cuff. Some patients can still be adequately bagged with a cuffless trach. Not all home care adult ventilator patients have cuffed trachs. Don't be surprised to see a trach patient wearing a NC especially if they want to be mobile or the trach is capped. Always ask for the spare model or box and the emergency equipment that should be customized for that patient and at bedside if in a NH. Make sure the cuff is deflated before placing a speaking valve. Here's some different models: http://www.trachs.com/cart/xcart/customer/home.php?cat=253 Montgomery http://www.bosmed.com/about.html Blom Singer tubes http://www.inhealth.com/featuredproductlaryngectomytubes.htm Shiley tubes http://www.dhmc.org/webpage.cfm?site_id=2&...mp;item_id=8169 http://www.nellcor.com/prod/list.aspx?S1=AIR&S2=TTA Portex® Trach-Talk™ Blue Line® Tracheostomy Tubes http://www.smiths-medical.com/catalog/port...-talk-blue.html Bivona Tubes http://www.smiths-medical.com/catalog/bivo...heostomy-tubes/ The Bivona Foam cuff tube always gives providers problems because the cuff inflates with ambient air so the pilot balloon is uncapped. To deflate fully for removal, you need a stopcock and 20 cc syringe (12 cc will do) and quickness. http://www.smiths-medical.com/catalog/bivo...t-fome-cuf.html Link to comment Share on other sites More sharing options...
Just Plain Ruff Posted March 4, 2008 Share Posted March 4, 2008 ok we went from a post on Jan 10 to a new post on March 2. I suspect Shannon forgot what she originally posted this for. This leads to a suggestion to all who post scenarios. If you post a scenario you better be available to answer questions about it. You put yourself out as a scenario expert and when you don't respond to the questions from the group it makes you look incompetent. so bottom line, if you post a scenario please stick around until the scenario has reached it's logical conclusion. There have been a number of scenarios posted with responses for a while and then the original poster vanishes leaving those who replied in the dark. Don't get me wrong, there are lots of good scenario posters out there but some others are not so good. Link to comment Share on other sites More sharing options...
Recommended Posts