# Non-vent trach transports



## Incyder38 (Apr 23, 2010)

Just wondering if any of you BLS companies spend any time training EMT-B's on the function and support of patients with a trach.  The proper way to suction a pt came under discussion yesterday, and it seems a lot of EMT-Basics are petrified to perform this basic skill.


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## Shishkabob (Apr 23, 2010)

Suctioning a trach isn't a "Basic" skill, it's an advanced provider skill as it's technically invasive, and has a risk for infection.  It's taught in paramedic curriculum, but not in EMT.   Trachs that need constant monitoring/suctioning should have a paramedic doing it, or an Intermediate if it's in their scope.


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## Incyder38 (Apr 23, 2010)

We transport them BLS out here in Orange County.  I'm pretty sure the reason why is that the only ALS providers are Fire Medics (or nurses...but I dont think they can justify a non-vent trach as a CCT call) Also, there is a hospital less than 5 minutes from almost anywhere in O.C.


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## TransportJockey (Apr 23, 2010)

The company I used to work for tried to send me on a 6+ hour run with a trach pt. Wound up having to send another truck on it instead since I was attend only on a BLS rig at the time and I pointed out that it technically was outside the basic scope in NM (and this was all of a week after I finished third rides and was cleared to operate on a truck as the second crew member)


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## VentMedic (Apr 23, 2010)

The thing about California EMS allowing BLS to transport trach patients is that they can not do suctioning that is considered invasive or "deep suctioning" although that should only be the length of the trach and not to the bottom of the lungs.  The EMTs are limited to suctioning with tonsil tip or Yankauer suction.  Attempting to stick this type of suction device into the trach will get any RN, LVN or patient and their family member scolded with a serious re-education/re-training session.  Yet, this is what is taught to EMTs.   The Yankauer that is laying around open, usually dangling near the floor, is contaminated and will introduce many nasties into the airway.  It can also form a seal in the trach which can cause atelectasis.  

If you are not allowed to proper suction a trach with sterile technique with the appropriate sized suction catheter, you have no business with that patient.  

If you do not have the ability to unplug a trach beyond what the "Yankauer" can reach, you have no business with that patient.

If you do not know when a trach is dislodged or false tracked, you have no business with that patient.

If you can not replace that trach with another or something else like an ETT, you have no business with that patient. 

If the trach falls out and if you have not been taught to rescue a trach patient properly with a BVM or if the patient has a condition which makes the  upper airway less patent, you have no business with that patient.

If you do not understand the different types of trachs or know the differences between cuffed, uncuffed or fenestrated, you have not business with that patient. 

How many Paramedics would place an ETT and then let the EMT-B "BLS" the patient to the ED?   The trach is an artificial airway which is there for a reason. 

Families and patients are at least taught extensively about the trach if they are in the home situation.  If the patient is not conscious or has not received extensive training about their trach when you transport, unless you have all the above mentioned education you have no business taking care of that patient.


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## VentMedic (Apr 23, 2010)

Incyder38 said:


> Also, there is a hospital less than 5 minutes from almost anywhere in O.C.


 
Thus, when the trach becomes plugged all you can do is run L&S real fast to the nearest hospital while the patient is turning blue.


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## Incyder38 (Apr 23, 2010)

Awesome post, VentMedic.  I agree on all points.  Which is why I think we should all do some supplemental training on this topic.


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## WolfmanHarris (Apr 23, 2010)

Couldn't agree more with Vent!
A PCP crew wouldn't be approved to transfer a trach'ed pt. to begin with, and if we were I'd have to refuse the transfer unless an escort was attending. These calls would either be assigned to ORNGE (Provincial, non-profit CCT and Air provider), to an ACP crew (depending on the service; some won't allow those resources to get tied up with IFT's) or to a PCP crew with RN or RT escort.

Part of being a patient advocate is recognizing when you're out of your depth and refusing to put your patient at risk.


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## CAOX3 (Apr 23, 2010)

Ok im confused a trach patient, not vented, trached goes CCT or by helicopter?

If you can teach family members to care for these patients why wouldnt you train your EMS providers?


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## TransportJockey (Apr 23, 2010)

CAOX3 said:


> Ok im confused a trach patient, not vented, trached goes CCT or by helicopter?
> 
> If you can teach family members to care for these patients why wouldnt you train your EMS providers?



Perfectly acceptable for them to go by medic. But most BLS providers don't have the knowledge to know what they're doing with a trached patient


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## VentMedic (Apr 23, 2010)

CAOX3 said:


> Ok im confused a trach patient, not vented, trached goes CCT or by helicopter?


 
CCT in some places may just mean ALS. In CA, Paramedics are rarely used for IFT transports since they are very limited by their scope. This means there is an RN on the transport. However, after reading some of the recent threads, I am becoming more inclined to believe that California has the correct idea. As long as Paramedic education stays at an average of 1000 hours or less in some places, they probably shouldn't be doing much more than what is in the California scope of practice. 

Why would you want to use a helicopter just because they have a trach? 



CAOX3 said:


> If you can teach family members to care for these patients why wouldnt you train your EMS providers?


 
Families have a vested interest in the trach of their loved one. They will be taking care of that trach everyday and utilizing certain skills like suctioning several times a day. To teach an EMT a skill that they may or may not use or use very rarely and with no monitoring for competency, might be a little futile. Also, few EMTs will want to learn this skill since it is one that is associated with chronic patients and BS nursing home calls. Even Paramedics who have suctioning in their scope of practice fumble or just totally lack any knowledge of sterile technique suctioning. I have found this out when I ask them to demonstrate suctioning the patient before they embark on a long distance transfer. If you have no idea about clearing the airway, you don't need to be taking the patient until until you do know how.


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## JPINFV (Apr 23, 2010)

CAOX3 said:


> Ok im confused a trach patient, not vented, trached goes CCT or by helicopter?
> 
> If you can teach family members to care for these patients why wouldnt you train your EMS providers?



I think the bigger issue is why is an *individual* patient going by ambulance than other modes of transport. If a true medical necessity for transport by ambulance is needed, then it's important that the providers on board know how to handle contingencies. On the other hand, if it's a pure horizontal taxi transport, then the question is why does the person need an ambulance at all versus other modes of transportation? A trach, by itself, isn't a reason for ambulance transport, little less a CCT or paramedic transport. However, a patient with a trach and an appropriate medical need for ambulance transport very easily begins to exceed the capabilities of an EMT level ambulance.


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## VentMedic (Apr 23, 2010)

JPINFV said:


> I think the bigger issue is why is an *individual* patient going by ambulance than other modes of transport. If a true medical necessity for transport by ambulance is needed, then it's important that the providers on board know how to handle contingencies. On the other hand, if it's a pure horizontal taxi transport, then the question is why *does the person need* an ambulance at all versus other modes of transportation? A trach, by itself, isn't a reason for ambulance transport, little less a CCT or paramedic transport. However, a patient with a trach and an appropriate medical need for ambulance transport very easily begins to exceed the capabilities of an EMT level ambulance.


 
Taxis rarely have oxygen and suction. Depending on the distance of the transport, an E tank might not be enough. These transports are ususally IFTs. I doubt if any hospital, rehab or subacute is going to risk liability of sending their patient by taxi. 

If the patient is transported from home by helicopter, the ground EMS crew probably made that call and not the patient.
CCTs are generally used for IFTs and rarely take or pick up a patient from home. If the patient is discharged home, they can be taken by their family unless there are other medical issues. 

Again, some in EMS believe they are the only means of transport and don't actually realize how many patients do go by other modes. However, those patients who do end up in the ambulance are criticized as if it is their fault.

But then we have more generalizations that all trachs are the same and all patients with trachs should be treated the same. Not all trachs will look like the one pictured in some Paramedic text books.  There are also many medical reasons why a trach is placed.


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## JPINFV (Apr 23, 2010)

Maybe not taxi, but why not wheel chair van? Plenty of extended care facilities also run their own shuttles, especially for planned outtings. There are forms of medical transport below an EMT level ambulance. Additionally, not all trach patients are on oxygen. In fact, I know this because my mother spent at least a year at home with a trach before she was able to have reconstructive surgery to repair her trachea. We didn't call an ambulance (of any level) every time we left the house, she wasn't on oxygen, and I can't remember if she ever needed deep suctioning (I was in grade school at the time).


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## VentMedic (Apr 23, 2010)

JPINFV said:


> Maybe not taxi, but why not wheel chair van? Plenty of extended care facilities also run their own shuttles, especially for planned outtings. There are forms of medical transport below an EMT level ambulance.


I already stated that. Some in EMS believe they are the only one transporting patients and have no idea how many patients use alternate means. The ones an IFT might see is for a reason which could include the patient being unable to suction themselves. 



JPINFV said:


> Additionally, not all trach patients are on oxygen. In fact, I know this because my mother spent at least a year at home with a trach before she was able to have reconstructive surgery to repair her trachea. We didn't call an ambulance (of any level) every time we left the house, she wasn't on oxygen, and I can't remember if she ever needed deep suctioning (I was in grade school at the time).


 
Not all trachs are the same. Those that don't need O2 may require humidification especially if they have thick secretions or the transport is long. Some may wear a type of HME during the day and use an aerosol generator at night. 

You are arguing about this about because of *a* trach patient you saw when you were a little kid? Not all trach patients will be like the one from your childhood memories. Your mother may not have suctioned this child in front of you in fear you might get sick or to avoid embarrassing the child. These are also things you have to consider as a healthcare professional before you do certain invasive procedures.


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## JPINFV (Apr 23, 2010)

VentMedic said:


> You are arguing about this about because of *a* trach patient you saw when you were a little kid? Not all trach patients will be like the one from your childhood memories. Your mother may not have suctioned this child in front of you in fear you might get sick or to avoid embarrassing the child. These are also things you have to consider as a healthcare professional before you do certain invasive procedures.



Yes... my mother is but a figment of my memory and a year is a desperately short time too. I actually can recall a lot about all three hospitals she was in (including the month she spent in the ICU on a vent, which I was allowed in to visit), as well as when she went in to have her trachea reconstructed a year or so after being discharged from the last hospital (she wasn't restrained following it being inserted, so when she started to come around her first night in the ICU she decided to remove it...). 

Making me sick? I've seen her suctioned at that age and witnessed a fair amount of her in-hospital care. Then again, I was more fascinated than horrified or sickened when I first saw her in the ICU with half a dozen IVs, anti-embolism pneumatic device (I only had a vague understanding of what it was then), a ventilator attached to her throat, a feeding tube up her nose, and a dozen other things that had blinking lights and made beeps (I also actually knew what most of those were prior to her having a stroke. See... Rescue 911 does teach kids things.). The much more plausible reason would be this thing kids are at for a large portion of the day called school in addition to scouts, church, base ball, and all the other extracurricular activities that takes up a good chunk of the day. 

The point still stands that a trach, on its own, is not an indication for medical transport. Since you're agreeing with this and for some reason getting upset over, what, I don't know (maybe we were a bad family for not asking for an ambulance or a nurse every time we went out to eat, shopping, or anything else people do in their normal daily life outside of the home), I'm going to stop hitting the "view post" button above the "this person is on your ignore list" part. Hence why transportation decisions should be based on more than 'ZOMG THAT PERSON HAS A TRACH, CALL A CCT UNIT!'


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## VentMedic (Apr 23, 2010)

JPINFV said:


> Hence why transportation decisions should be based on more than 'ZOMG THAT PERSON HAS A TRACH, CALL A CCT UNIT!'


 
The patient should be transported by a person who is best capable of taking care of that trach. If an EMT (or any health care professional) is not properly trained to take care of a trach, they have no business transporting or caring for that patient. If the only transport team capable of caring for a trach is on a CCT, then that should be the service called. If an EMT-B is capable of PROPERLY CARING for a trach, then that level could be considered. 

Do not fault the patient or put them at risk because of the lack of EMS training and the inadequacies of different EMS levels and transport companies. 

The rest of your post just enhances what I have said about all the different medical conditions that require a trach. Don't write a trach patient off as a BS call unworthy of an EMT or CCT unless you know why that patient has the trach and what medical conditions still exist. Also, some of the CCTs in California have the option of transporting as "BLS" with the EMT-B attending which isn't the most comforting but at least the RN is still in the truck.

And again...
EMS and ambulances will not see every trach patient. In fact they will see very few which is probably why suctioning a trach is not a "skill" emphasized in EMS training.

I don't know how much clearer I can make it to JP that there are other means of transport used including the patient's family. EMTs are most likely to see trachs on IFTs and no hospital or SNF is going to send a patient by taxi or POV if they are still under their care. If a shuttle or other means of transport can be used, it probably will be. If a patient is going from SNF or subacute to a hospital for acute care, chances are a medical transport capable of taking a trach will be utilized and not just a non-medical shuttle.


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## CAOX3 (Apr 23, 2010)

I believe more education is needed for all and also more distict training because more and more of these individuals with signifigant care are living at home.  So the 911 EMT/paramedic has more of an oppurtunity to come in contact with these patients.

I have seen some amazing people living at home.  Children an adults on ventilators.  IV heparin and various other medications, in home dialysis and so on.  

We do not deep suction here, but in my original EMT class we did because back then intubation was in the protocols.


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## VentMedic (Apr 23, 2010)

CAOX3 said:


> I have seen some amazing people living at home. Children an adults on ventilators. IV heparin and various other medications, in home dialysis and so on.


 
Hopefully, just like the LVAD patients, their caregivers will accompany the patient.   

There have been many attempts to offer more education classes to the various EMS agencies and ambulance services but again, these are "chronic" patients and of little interest to EMTs and Paramedics.   Few EMT(P)s show up for something like trachs, home vents and venous access device classes.  Even for LVADs there is very  little interest and those patients are in the community as well.


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## CAOX3 (Apr 23, 2010)

In my experience they will accompany them.  Most will have their personal vent which the caregiver is trained to operate.  

As far LVAD s I have only been on one call it was for a power outage and the gentlemen couldnt locate his hand pump so we just assisted him.

We did have con ed on them, very interesting especially with CPR in which you would just use the pump instead of compressions in some cases but I havent had any experience with that as of yet.  We were directed to locate model and number and to contact medical control as to how to proceed with handling a cardiac arrest with these devices.


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## Sam Adams (Apr 23, 2010)

VentMedic said:


> To teach an EMT a skill that they may or may not use or use very rarely and with no monitoring for competency, might be a little futile.



As non-confrontational as I can type this: Can I infer from this that you also believe EMT's should not be taught the Heimlich Maneuver? The Jaw Thrust? Tourniquets? Traction Splints? APGAR scores? The Rule Of Nines? ...

Essentially what this whole thing comes down to is a UNIVERSAL lack of legitimate CON-ED and for that matter ED in EMS. It absolutely amazes me. This topic in particular, airway management, should be beaten like a dead horse. Airway opening and positioning, BLS ajuncts (OPA's and NPA's), suctioning with the different catheters.... You can't get to the Breathing part of your patient until the Airway has been managed. 

Getting back to the topic at hand, should non-emergent, non-vented trach transports go BLS? Yes. Are we as a profession there yet? Not even close.


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## VentMedic (Apr 23, 2010)

Sam Adams said:


> As non-confrontational as I can type this: Can I infer from this that you also believe EMT's should not be taught the Heimlich Maneuver? The Jaw Thrust? Tourniquets? Traction Splints? APGAR scores? The Rule Of Nines? ...


 
The Heimlich Maneuver and Jaw Thrust are part of CPR and must be renewed at least every 2 years. Tourniquets are controversial and not every service has implimented the protocols for them again or yet. Traction splints should still be part of EMT training as should APGAR scores and the Rule of Nines. However, there is just so much a 110 hour course can teach. I would like to see the education/training of the EMT raised to the length of what the U.S. Paramedic is now or more with at the bare minimum of 1 semester of college level A&P as a prerequisite to entry. But then, EMT and Paramedic courses should be taught at a college in the division of health professions if EMS wants to be part of healthcare. 

We could also look at the "skills" of the Paramedic. Those who only intubate or start an IV once a year are not going to be as up on their skills if they are not reviewing and practicing on some other source. Thus, we now have some ALS EMS agencies moving away from ETI and using alternative airways. 

I am all for teaching the EMT how to suction but if their scope of practice does not allow for it or there is not a system in place to monitor an invasive skill, who is to say they will remain proficient at this "skill"? 

Also, just as a little curiousity poll, ask your co-workers to run through the APGAR score and the Rule of Nines just to see how much they remember from EMT school.

As a sidenote, I do teach my trach patients and those on a ventilator to be able to talk someone through their technology and procedures such as clearing their trach if they are able. Unfortunately, if a mucus plug strikes at the wrong time, they may not be able to do this.

EMT(P)s should also be familiar with speaking valves and know the difference between a laryngectomy patient with a tracheostomy stoma as well as those with a tracheotomy.


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## bstone (Apr 25, 2010)

Non-vent trach calls have been a long-standing BLS transport when I worked in Chicago. We regularly would do IFTs on these pts. We used french suction catheters frequently and regularly.


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## firecoins (Apr 25, 2010)

VentMedic said:


> The patient should be transported by a person who is best capable of taking care of that trach. If an EMT (or any health care professional) is not properly trained to take care of a trach, they have no business transporting or caring for that patient.
> .


Makes sense



bstone said:


> Non-vent trach calls have been a long-standing BLS transport when I worked in Chicago. We regularly would do IFTs on these pts. We used french suction catheters frequently and regularly.



Same here.


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## VentMedic (Apr 25, 2010)

bstone said:


> We used french suction catheters


 
For a little clarification, French refers to the size of the catheter and not necessarily the type of catheter. Some semi-rigid (Coude, bronchitrac) and rigid catheters are also sized by the French (Fr) measurement as well as urinary catheters, feeding tubes, cardiac catheters and chest tubes.

French = Diameter in mm x 3

# French suction catheter 

Since there are many types of suction catheters, you may hear a brand name such as Bard or Ballard used and the type such as inline, closed or red rubber (latex). Some are trying to break the habit of using brand names since it becomes a habit even when that brand is not being used. An example of this is using "Ambu" bag instead of just saying BVM or the specific type of bag and correct brand name.


By using the term "French" with the item, it is similar to using the measurement term "gauge" with needles. Gauge can also apply to many other items as well. 

# gauge angiocath

# gauge hypodermic

Diameter = 1/gauge

However, the larger the gauge the smaller the diameter whereas for French as the number increases so does the diameter.


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## VentMedic (Apr 25, 2010)

I probably should explain why understanding what "French" is can be important.

As I already mentioned:

French = Diameter in mm x 3

ETTs and trachs are measured by diameter in mm.

7.0 ETT has a diameter of 7.0 mm.

For trachs the sizing can be a little odd but you will find the ID (inner diameter in mm) and OD (outer diameter in mm) written on the trach flange.

Now if we multiply the diameter of the ETT or ID of the trach by 2 we get a French size catheter that is 2/3 the inner diameter (or 2/3 the French conversion size) of the trach or tube.  By the text book we would then choose one size smaller as the correct suction catheter or approximately 1/2 the inner diameter.


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## WolfmanHarris (Apr 25, 2010)

Some may have also noticed their NPA's are sized in French.


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## Incyder38 (Apr 25, 2010)

VentMedic, thanks for all the info.  This is exactly why I started this in the first place.  To get people to think about these pt's.  I know for a fact that a lot of EMT-B's transport these pt's, and are lucky that something requiring an intervention doesn't happen.  although it's in the Orange County BLS protocols, doesn't mean that everyone is prepared to handle these pt's.


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