# IFT Trach Patients by BLS.



## Lannel (Aug 2, 2015)

Hi there. I currently work for an IFT company as an EMT-B, as it's my first year in EMS and apparently this is how I'm supposed to get my foot in the door. Anyways, my questions pertains to transporting Trach patients as an EMT-B. 

Sometimes, these transports can be up to 1 1/2 hours to 2 hours long. As an EMT-B, I was not properly trained to suction trach patients, and in my area it is an ALS skill due to it being invasive. My first transport with a trach patient, we had a respiratory therapist ride along with us who performed suctioning during the transport, so I was okay with transporting the patient as she was well versed when it came to suctioning; however, this wasn't always going to be the case.

The next trach patient I had to transport, and ever since then... We've never had a respiratory therapist come with us. I was quite concerned with this my first time transporting solo, I asked the Nurse if she was sending anyone with us and she said no. When I brought up the fact that I wasn't trained to suction the patient's airway due to his trach, she said "he'll be fine". I called my dispatch and they told me to just go with what the nurse says and transport him. So, I did.

Recently however, we were transporting a patient with a trach and they started to sound very congested to the point where I had a pretty good concern for how long he'd be able to continue breathing. So, I called dispatch and told them to send a medic truck our way to perform some suctioning. Which they did, and my patient was fine and we continued the transport.

While the medic was suctioning, he himself was kind of curious as to why they had the patient being transported by a BLS crew. I told him I didn't really know, and that I to was pretty confused as to why it was a BLS transport instead of an ALS, even though from my experience it's common practice. He agreed with me that it should have been an ALS transfer, and after he completed the suctioning, he put my patient on 3 LPM of oxygen and we continued the transport.

Long story short, I'm wondering why it is that these transports with trach patients are put as BLS instead of ALS when suctioning the trach correctly is an ALS skill in my area.


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## PotatoMedic (Aug 2, 2015)

As long as they don't need suctioning, a simple trach does not need anything above bls.  Some places allow bls to be trained to do trach suctioning.


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## Jim37F (Aug 2, 2015)

I say good job on being mindful enough to preemptively request ALS when you think the patient will need a skill out of your scope BEFPRE the patient actually needs that skill.


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## Ewok Jerky (Aug 2, 2015)

Also, when transporting junky trach patients, don't lean in front of them when the cough.

I usually ask for a pre emptive suck before I leave the facility. 

And as stated, trach patients as stable for BLS as the general population, but don't be afraid to divert or request an intercept if you need an intervention.


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## Jn1232th (Aug 2, 2015)

I transported trachs alot (Mostly with t bar involved). We suctioned when needed but was very rare. If pt wascon vent it became a cct.


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## CALEMT (Aug 2, 2015)

Jim37F said:


> I say good job on being mindful enough to preemptively request ALS when you think the patient will need a skill out of your scope BEFPRE the patient actually needs that skill.


 
Agreed. 



Ewok Jerky said:


> I usually ask for a pre emptive suck before I leave the facility.
> 
> And as stated, trach patients as stable for BLS as the general population, but don't be afraid to divert or request an intercept if you need an intervention.



This. No harm in asking for suction before you get going. Like Ewok says trach patients are relatively stable and can go by BLS. If he needs a intervention thats out of your scope of practice then theres no problem calling for a higher level of care to preform said intervention. 

Good job in knowing when to call ALS.


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## DesertMedic66 (Aug 2, 2015)

Ewok Jerky said:


> Also, when transporting junky trach patients, don't lean in front of them when the cough.
> 
> I usually ask for a pre emptive suck before I leave the facility.
> 
> And as stated, trach patients as stable for BLS as the general population, but don't be afraid to divert or request an intercept if you need an intervention.


I don't think you could have worded that second statement any better...


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## Underoath87 (Aug 2, 2015)

If the patient needs "frequent trach suctioning", then it is ALS.  Otherwise, it's a BLS transport. 
So it usually comes down to the judgement of the nurse requesting the transport on behalf of the doctor who has no idea how much sputum the pt is producing.  Be sure to talk to the nurse/RT before leaving the facility to make sure you're not getting more than you bargained for due to a miscommunication.

And yes, one last suck "for the road" is always a good idea


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## gonefishing (Aug 10, 2015)

What area you from? Where im from its a bls skill unless your on a vent.


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## Underoath87 (Aug 10, 2015)

gonefishing said:


> What area you from? Where im from its a bls skill unless your on a vent.



Deep suctioning as a BLS skill?


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## gonefishing (Aug 10, 2015)

Underoath87 said:


> Deep suctioning as a BLS skill?


Not deep suctioning but suctioning of a trach.


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## Underoath87 (Aug 10, 2015)

gonefishing said:


> Not deep suctioning but suctioning of a trach.



That's the only real way to suction a trach (threading a soft suction catheter down to the corina). Otherwise, all you're doing is clearing the opening with a Yankhauer, which is pretty useless.


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## Underoath87 (Aug 10, 2015)

Granted, suctioning with an existing T-piece makes deep suctioning easier and safer, but it is still considered the same process as deep suctioning with sterile gloves and a soft cath.


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## gonefishing (Aug 10, 2015)

Underoath87 said:


> Granted, suctioning with an existing T-piece makes deep suctioning easier and safer, but it is still considered the same process as deep suctioning with sterile gloves and a soft cath.


This is a basic skill in LA county now and alot of other areas.


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## johnrsemt (Aug 16, 2015)

Hand the patient the suction tubing and let them suction themselves.  They don't call for a medic everytime they need suctioning at home.
Talk to your manager and your medical director.  If the Medical director says it should be ALS everytime then the company makes more money so they should be happy


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## 18G (Aug 27, 2015)

I'm surprised to hear that trach suctioning is not a BLS skill where you're at. In all three states I practice, EMT's suction trach patients.


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## Chewy20 (Aug 27, 2015)

gonefishing said:


> This is a basic skill in LA county now and alot of other areas.



Haaaa so LA can deep suction but can't use a pulse ox or dstick? Or did yall get those too?


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## gonefishing (Aug 27, 2015)

Chewy20 said:


> Haaaa so LA can deep suction but can't use a pulse ox or dstick? Or did yall get those too?


There are pulse ox now but "optional" bls equipment.  No dstick because the board for LA looked at OC and said well they never do it there so its a waste here.


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## redundantbassist (Aug 29, 2015)

gonefishing said:


> There are pulse ox now but "optional" bls equipment.  No dstick because the board for LA looked at OC and said well they never do it there so its a waste here.


The fact that a rig would carry o2 but not a pulse ox is incredibly stupid.


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## gonefishing (Aug 29, 2015)

redundantbassist said:


> The fact that a rig would carry o2 but not a pulse ox is incredibly stupid.


Not necessarily there is always cap refill.  You could walk into a house fire and come out with a saturation of 100% it's just like Private ALS companys in LA county not being able to pace unless having a special certification from the county and as well no requirement for cpap and also having to have a special certification from the county even though BOTH are taught in school.


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## redundantbassist (Aug 29, 2015)

gonefishing said:


> Not necessarily there is always cap refill.  You could walk into a house fire and come out with a saturation of 100% it's just like Private ALS companys in LA county not being able to pace unless having a special certification from the county and as well no requirement for cpap and also having to have a special certification from the county even though BOTH are taught in school.


Likewise, I feel that having a pulse oximeter discourages the mindset of "give everyone o2 no matter what" mentality that is ever so prevalent in the BLS community.

A patient who has an arm injury and has no signs of respiratory distress or hypoperfusion would most likely not need oxygen, and this would be confirmed by obtaining an spo2. On many conditions, providers at the BLS level would give such a patient o2 due to the fallacies in their limited training and protocols.


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## gonefishing (Aug 29, 2015)

redundantbassist said:


> Likewise, I feel that having a pulse oximeter discourages the mindset of "give everyone o2 no matter what" mentality that is ever so prevalent in the BLS community.
> 
> A patient who has an arm injury and has no signs of respiratory distress or hypoperfusion would most likely not need oxygen, and this would be confirmed by obtaining an spo2. On many conditions, providers at the BLS level would give such a patient o2 due to the fallacies in their limited training and protocols.


Exactly but there are some that state theres a ton of education to follow using a pulse ox which is BS I learned caponography in a day and think its one hell of a tool.  EMS in certain areas especially where its fire controlled beleive in the KISS system. (Keep It Simple Stupid) which only results in holding ems back education and skill wise.


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## redundantbassist (Aug 29, 2015)

gonefishing said:


> Exactly but there are some that state theres a ton of education to follow using a pulse ox which is BS I learned caponography in a day and think its one hell of a tool.  EMS in certain areas especially where its fire controlled beleive in the KISS system. (Keep It Simple Stupid) which only results in holding ems back education and skill wise.


Stupid protocols are written by stupid people.


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## gonefishing (Aug 29, 2015)

redundantbassist said:


> Stupid protocols are written by stupid people.


Well it's to protect stupid people.  Back in the mid 90's a LA Firefighter  Emt improperly used smelling salts on a patient.  He shoved 1 in each nostril pinched and cracked the vials in the patients nose leading to a major lawsuit.  As they say Jack of all trades master of none.


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## redundantbassist (Aug 29, 2015)

gonefishing said:


> Well it's to protect stupid people.  Back in the mid 90's a LA Firefighter  Emt improperly used smelling salts on a patient.  He shoved 1 in each nostril pinched and cracked the vials in the patients nose leading to a major lawsuit.  As they say Jack of all trades master of none.


I feel bad for laughing at that image


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## Tigger (Aug 29, 2015)

gonefishing said:


> Back in the mid 90's a LA Firefighter  Emt improperly used smelling salts on a patient.  He shoved 1 in each nostril pinched and cracked the vials in the patients nose leading to a major lawsuit.


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## johnrsemt (Aug 29, 2015)

You don't need pulse ox to decide if the patient needs O2 or not,  just like you don't need Blood Glucose reading to decide if your patient needs Oral Glucose or D-50. 
 What if your batteries in the glucometer die?  Pt is confused, and diaphoretic and family says that he is acting like he does when his sugar is low:  You are going to treat him.
  O2:  My normal Pulse ox is 92%,  but I don't need O2 on a normal basis.  When my asthma is acting up my Pulse ox goes up to 98-99% at first, but I might need O2.   Then it drops when asthma gets bad.    If you treat me by Pulse ox readings;  you will give me O2 on a good day and withhold it when I need it.

TREAT THE PATIENT NOT THE MONITORS


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## ERDoc (Aug 29, 2015)

johnrsemt said:


> You don't need pulse ox to decide if the patient needs O2 or not,  just like you don't need Blood Glucose reading to decide if your patient needs Oral Glucose or D-50.
> What if your batteries in the glucometer die?  Pt is confused, and diaphoretic and family says that he is acting like he does when his sugar is low:  You are going to treat him.
> O2:  My normal Pulse ox is 92%,  but I don't need O2 on a normal basis.  When my asthma is acting up my Pulse ox goes up to 98-99% at first, but I might need O2.   Then it drops when asthma gets bad.    If you treat me by Pulse ox readings;  you will give me O2 on a good day and withhold it when I need it.
> 
> TREAT THE PATIENT NOT THE MONITORS



No, this is all wrong.  This is why EMS as a whole is stuck in the 70s.  If the monitors didn't have any value or add anything to pt care then we wouldn't use them.  There is a reason we have developed all of these monitors and that is to provide better pt care.  Yes, you need a glucose reading to know if you are treating a hypoglycemic or a stroke.  I don't care what the family says, people with hypoglycemia can have other things wrong, including strokes and stroke mimics.  Are you going to give D50 to someone in DKA?  When your asthma is "acting up" and your pulse ox is 98%, you don't need oxygen, you need albuterol and atrovent.  Why would anyone give you oxygen on a good day?  A pulse ox of 92% is no reason for oxygen.

The monitors are an integral part of pt care.  They become an extension of the patient and an extension of the provider.  They fill in so much detail of the overall picture that to dismiss them as not needed is to demonstrate that their purpose, function and use is poorly understood.


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## Carlos Danger (Aug 29, 2015)

Yeah, monitors are just a scam....patients got waaay better treatment before we got duped into buying all these these fancy 'ometers and 'oximeters.

Amiright!?

D50 for all the stroke patients!!!!


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## Tigger (Aug 30, 2015)

Clinical correlation.


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## systemet (Aug 31, 2015)

ERDoc said:


> Yes, you need a glucose reading to know if you are treating a hypoglycemic or a stroke.  I don't care what the family says, people with hypoglycemia can have other things wrong, including strokes and stroke mimics.



To expand on this for some of the newer BLS providers, you will see plenty of old people, many on beta-blockers who don't present with typical symptoms when they're hypoglycemic.  You will see overdoses on insulin or oral hypoglycemics, and many other drugs (e.g. propanolol) that become hypoglycemic. You will meet people who are drunk, overdosed on opiates, and have head trauma who are also hypoglycemic.  You will certainly see tons of sick kids that have hypoglycemia as a contributing factor.  You will see hypoglycemic with lateralised deficits. 

Not to even get started on hypoglycemia.  I had a guy yesterday who presented as drunk and tachycardic, whose glucose was 35 mM ( 650 mg/dl).  Want to send him to the drunk tank? Or the local homeless shelter?  




> When your asthma is "acting up" and your pulse ox is 98%, you don't need oxygen, you need albuterol and atrovent.  Why would anyone give you oxygen on a good day?  A pulse ox of 92% is no reason for oxygen.



Not to mention, sometimes you look at the patient, and that don't seem that bad, then you look at the monitors, and you go, hey, while this guy is compensating, objectively he's probably much worse than I think.  Let's re-evaluate where we're sitting.

That's why things like PRAM scores ( http://www.albertahealthservices.ca/Information For/if-hp-emerg-nurs-educ-ped-asthma-pathway.pdf ) exist. Because there's a whole lot of research that goes into how we treat people, and is used not just by EMTs, RNs and Paramedics, but also by the Physicians.  If they're doing it, maybe we should, too?


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## Rano Pano (Aug 31, 2015)

Remi said:


> Yeah, monitors are just a scam....patients got waaay better treatment before we got duped into buying all these these fancy 'ometers and 'oximeters.
> 
> Amiright!?
> 
> D50 for all the stroke patients!!!!


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## medichopeful (Aug 31, 2015)

johnrsemt said:


> TREAT THE PATIENT AND THE MONITORS



Fixed it for you!

Monitors and other assessment tools are there for a reason.  They provide information that should be used to provide an overall clinical picture.  If the monitor is saying something funky that doesn't seem to fit, the information shouldn't be simply thrown out, but rather looked into further.

That being said, if the monitor is saying something completely false (first thing that pops into my head is asystole when you're talking to them), than I would say it's safe to take it with a grain of salt .  However, that's different than simply saying "treat the patient not the monitor."


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## hogwiley (Jan 5, 2016)

It's not rocket science, cnas do it all the time, however you should be trained on how to do it, in as sterile a manner as possible. They can have a stubborn mucus plug, so it's good you are cautious, it means you're a conscientious emt. It's the overly confident yet inexperienced emts that scare me.

Why not ask the rt or medic how to do it when they were doing it? 

Also you should know what to do in the case of decannulation, especially if they have an altered mental status or dementia. Trachs have an inner cannula and outer cannula. Inner canula coming out not a huge deal. Outer cannula coming out can be, especially if it's a relatively recent trach(in which case it wouldnt be bls).


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## RocketMedic (Jan 7, 2016)

gonefishing said:


> Not necessarily there is always cap refill.  You could walk into a house fire and come out with a saturation of 100% it's just like Private ALS companys in LA county not being able to pace unless having a special certification from the county and as well no requirement for cpap and also having to have a special certification from the county even though BOTH are taught in school.



How many flaming/CO poisoning nursing home patients do these private ALS companies run?


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## hogwiley (Jan 9, 2016)

I've never understood not letting bls use a pulse ox. Just educate them that a low spo2 reading can be the result of poor circulation so they don't freak out when a 92 year old gramps initially shows 74. Just try different fingers and toes and see if the reading is the same and if they are symptomatic. 

They are useful tools and often the first thing I'd put on a patient while doing my assessment, seeing how it matched up with everything else I'm seeing while getting a baseline reading. They're supplemental tools and not definitive and that's pretty well driven home in emt school.

Companies just don't trust emts not to lose them and don't want to pay for them.


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