ALS or BLS?

[exodus]

In most places deep suctioning is an ALS skill considered invasive. BLS can't do it. ALS also has ETCO2 + Capnography and SPO2 to better monitor the airway and the ability to intubate the trach if gets jacked up.

 

[Veneficus]

ALS also has ETCO2 + Capnography and SPO2 to better monitor the airway and the ability to intubate the trach if gets jacked up.

Honestly, in a trach patient, if you need a devise to tell you the airway is compromised, you probably missed someting obvious.

The ability to intubate is not always possible. In procedures like laryngectomy, the trachea is attached directly to the fistula wall. There is no longer a passage between the upper and lower airway.

Other problems like neoplasm or already advanced upper airway swelling from various procedures may have required the trach to begin with.

I am not suggesting ALS shouldn't have handled this call, only that is could adequetely be done by properly utilized and experienced BLS.

If your area doesn't allow BLS to suction trachs, I would point out that laypersons are taught to do that for both adult and peds on homecare, so your medical direction may want to join the modern world.

 

[DownSouthMedic]

So did you tell your supervisors about it? Or just us?

If the facts aren't skewed, and I'm not saying they are, what those medics did was negligent and abandonment. If it had gone south even a brand new, bottom of the barrel lawyer could prove it.

I know it sound's like I'm just trying to trash this ALS crew, but I have not exaggerated at all. Ultimately we transported the PT with no further complications, but looking back I should have just called the ALS crew back. I will be notifying my supervisor about this next shift.

 

[Anjel]

I know it sound's like I'm just trying to trash this ALS crew, but I have not exaggerated at all. Ultimately we transported the PT with no further complications, but looking back I should have just called the ALS crew back. I will be notifying my supervisor about this next shift.

I wouldnt wait. Call now. The longer you wait the more chance of mixing up the facts.

 

[triemal04]

For certain this was an ALS call. It should have been handled by competent ALS providers. If this is an accurate rendition of events, it was definately unprofessional behavior on the part of the medics. Fleeing the scene is generally not professional behavior.

But in the absense of a competent ALS provider, with the ability of tracheal suctioning, a basic skill in some places like my home state, what exactly makes this way above an EMT?

See? See what having a little common sense will do? It'll make you say silly things like this and cause the equivalent of crickets to start chirping in a thread...oh so funny...and accurate.

The only thing I'd be to worried about with this patient wouldn't be so much airway swelling (well, actually it would be, from a different cause) but a build-up of subq air; depending on where the bleeding was coming from and how much damage had been done I could see that being a problem, especially if positive pressure ventilations were ever used. Which didn't seem to be a problem in this case. That isn't neccasarily the end of the world, but that would take a competant paramedic to maintain the airway. Having a paramedic ride this patient in would probably be a good idea for that reason.

But beyond that...everyone who is immedietly jumping on the "I need a paramedic NOW" bandwagon...why? Once again, ignore your personal bias and "experience" and come up with a valid medical reason that this patient needed a paramedic RIGHT THEN. Not in 5 or 10 minutes, not in a worst case scenario, but as presented, and IN THAT CONDITION.

 

[Veneficus]

The only thing I'd be to worried about with this patient wouldn't be so much airway swelling (well, actually it would be, from a different cause) but a build-up of subq air; depending on where the bleeding was coming from and how much damage had been done I could see that being a problem, especially if positive pressure ventilations were ever used. Which didn't seem to be a problem in this case. That isn't neccasarily the end of the world, but that would take a competant paramedic to maintain the airway. Having a paramedic ride this patient in would probably be a good idea for that reason..

For the sake of continued discussion, what is your plan if those worst case events were to transpire?

 

[Medic Tim]

Def an ALS call. Any airway compromise or possible airway comprise gets ALS if available

 

[triemal04]

For the sake of continued discussion, what is your plan if those worst case events were to transpire?

Tell the EMT on scene that it's now his call, run out the door, go back to quarters, curl up in the corner while sucking my thumb and hope my medical director doesn't find me...:rofl:

I'm not sure what the best way would be. If there is a buildup of subq air it's either because the trach tube is in a false lumen, or there is enough damage below/near the end that any positive pressure is forcing air in. (Like I said, I think this would be more a problem with positive pressure, not spontaneous breathing, but I'm not positive; probably still be a problem, but maybe not as bad).

Best idea would be to GENTLY pass an eschmann through the trach to ensure that you had access to the trachea and wouldn't create a new false lumen when you replaced the trach, and GENTLY replace it with an ET tube. Assuming that it did enter the trachea, it'd have to be inserted deep enough so that the balloon was below the site where air was entering the skin; potentially this could mean only ventilating 1 lung. The balloon also might need to be overfilled.

And the liberal use of diesel.

That's the first thing that pops into my head, and really, I don't know what else would/could be done in the field. Honestly, I'm not sure anything else could be done in the hospital; the cause for the subq air needs to be fixed, but sutures or otherwise, but the lungs still need to be ventilated.

 

[triemal04]

Oh, and get on the phone with the hospital and tell them to get anesthesia and ENT into the ER immedietly.

 

[Veneficus]

If there is a buildup of subq air it's either because the trach tube is in a false lumen, or there is enough damage below/near the end that any positive pressure is forcing air in. (Like I said, I think this would be more a problem with positive pressure, not spontaneous breathing, but I'm not positive; probably still be a problem, but maybe not as bad).

I am not sure I understand this?

If the tube was pulled out, I would suspect a false lumen between the skin and trachea. That shouldn't be difficult to identify. As you bag, it would get worse.

My simple minded solution would be to decompress this lumen, leave the tube in it, and put an ET tube in the proper lumen.

There is also a real possibility if the trachea was surgically connected to the stoma that it was traumatically mobilized. In which case you simply have to find it and put a tube in it.

But here is where I don't quite get what you are saying.

You potentially suspect an actual hole in the anterior or posterior trachea?

Anterior, I would definately doubt. Just because of the actual cartilage ring construction and the real quantity of them.

Posterior could occur if somebody was a little too forceful replacing a beveled trach tube. In which case you now most likely have a hole into the mediastinum which if no other way out you would expect to see gastric distention or less likely signs of a tamponade.

If the esophagus was penetrated by the replacement attempt, it would be a surgical emergency for sure, but I doubt a rapidly decompensating one, more of a sepsis risk.

Could you clarify what you mean?

 

[triemal04]

I am not sure I understand this?

If the tube was pulled out, I would suspect a false lumen between the skin and trachea. That shouldn't be difficult to identify. As you bag, it would get worse.

My simple minded solution would be to decompress this lumen, leave the tube in it, and put an ET tube in the proper lumen.

There is also a real possibility if the trachea was surgically connected to the stoma that it was traumatically mobilized. In which case you simply have to find it and put a tube in it.

But here is where I don't quite get what you are saying.

You potentially suspect an actual hole in the anterior or posterior trachea?

Anterior, I would definately doubt. Just because of the actual cartilage ring construction and the real quantity of them.

Posterior could occur if somebody was a little too forceful replacing a beveled trach tube. In which case you now most likely have a hole into the mediastinum which if no other way out you would expect to see gastric distention or less likely signs of a tamponade.

If the esophagus was penetrated by the replacement attempt, it would be a surgical emergency for sure, but I doubt a rapidly decompensating one, more of a sepsis risk.

Could you clarify what you mean?

I don't know about decompression...I haven't seen subq air from this particular cause, but with others it was over a wide enough area that that wouldn't work. Even in this case I don't think it would; the air is going to spread out under the skin and I don't see one needle fixing that. Or did you mean something else? And if you left the misplaced tube in place, how would you pass an ET tube into the correct pasage; your access to the stoma is blocked. Standard oral intubation? Crich?

The trach tube being in a false lumen (I think there's an actual term for when that happens but damned if I can remember) would be a concern, but I doubt it would be the cause; if it was it would be a problem almost immedietly after the trach tube was put in the wrong place, not later on. And, yes, I would be a bit worried about the cause being someone being to forcefull in replacing the tube and causing more damage and potentially tearing the trachea, or creating a new passage between the skin and trachea.

Even if it went through the back of the trachea I think you'd see some subq air though, not positive but it seems like it'd still come up.

I was thinking more along the lines of this becoming a problem later on, not initially. In that case I'd be more worried that, in pulling the trach tube out the patient caused enough damage to either her trachea (actually doubt that'd happen) or the tissue above it that air under pressure would start to enter the skin. Or that happenign when the tube was replaced.

Did that make it more clear, or more confusing?

 

[Veneficus]

I don't know about decompression...I haven't seen subq air from this particular cause, but with others it was over a wide enough area that that wouldn't work. Even in this case I don't think it would; the air is going to spread out under the skin and I don't see one needle fixing that. Or did you mean something else? And if you left the misplaced tube in place, how would you pass an ET tube into the correct pasage; your access to the stoma is blocked. Standard oral intubation? Crich?

The trach tube being in a false lumen (I think there's an actual term for when that happens but damned if I can remember) would be a concern, but I doubt it would be the cause; if it was it would be a problem almost immedietly after the trach tube was put in the wrong place, not later on. And, yes, I would be a bit worried about the cause being someone being to forcefull in replacing the tube and causing more damage and potentially tearing the trachea, or creating a new passage between the skin and trachea.

Even if it went through the back of the trachea I think you'd see some subq air though, not positive but it seems like it'd still come up.

I was thinking more along the lines of this becoming a problem later on, not initially. In that case I'd be more worried that, in pulling the trach tube out the patient caused enough damage to either her trachea (actually doubt that'd happen) or the tissue above it that air under pressure would start to enter the skin. Or that happenign when the tube was replaced.

Did that make it more clear, or more confusing?

more confusing, but I think I got it.

I was thinking if the sub Q air was so massive it was displacing the trachea posterior to it because of a false lumen, there may still be airflow into the lungs at some level.

I figured in such a case, laterally decompressing by pinching the skin to avoid impaling a critical structure like a carotid, would relieve enough air to return the trachea to a visible position.

The stoma is usually wider than the tube, especially an ET tube, so it may not be fully occluded. You may also be able to cut and extend the stoma. (as an emergent airway maneuver if there was decompensation)

As I eluded to earlier, because most trachs I have seen placed were because of nonpatent upper airways, I would not consider that viable. I also think you would have much better luck going through the surgical opening for the trachea than creating your own cric below it. There is a completely disproportionate size of the holes created in the 2 procedures, and the trach is much larger.

 

[exodus]

Also, in what counties are paramedics authorized to replace trachs?

 

[triemal04]

more confusing, but I think I got it.

I was thinking if the sub Q air was so massive it was displacing the trachea posterior to it because of a false lumen, there may still be airflow into the lungs at some level.
That would be my concern, and while there probably still would be some flow to the lungs I'd still be very concerned with finding a way to resolve the issue of air entering the tissue; at some point it will compromise ventilations.

I figured in such a case, laterally decompressing by pinching the skin to avoid impaling a critical structure like a carotid, would relieve enough air to return the trachea to a visible position.
I don't follow. Are you meaning pinching the skin and then using a needle, or a scalpel? I don't get what you mean exactly. but it seems like a more sure way would be to place a tube in a position where it would not be forcing air into the tissue.

The stoma is usually wider than the tube, especially an ET tube, so it may not be fully occluded. You may also be able to cut and extend the stoma. (as an emergent airway maneuver if there was decompensation)
Gotcha.

As I eluded to earlier, because most trachs I have seen placed were because of nonpatent upper airways, I would not consider that viable. I also think you would have much better luck going through the surgical opening for the trachea than creating your own cric below it. There is a completely disproportionate size of the holes created in the 2 procedures, and the trach is much larger.Sure, the first choice would be to use the existing opening. A crich (above, given the location that I've seen most trach's in) would work I think, but you'd still need to pass a tube beyond the trach opening. Regardless of where the tube entered, it's a lousy situation. I wasn't kidding about requesting anesthesia and an ENT to be in the ER. That's interesting; most of the trach's I've seen were in place due to long-term dependance on a ventilator.

Sorry for the red, it's just easier. I doubt this would be a very likely situation anyway; it's just one of the only, if not the only real reason I can see for taking a patient like this in by paramedic, if the EMT's are able to do tracheal suctioning.

 

[triemal04]

Also, in what counties are paramedics authorized to replace trachs?

Oh...sorry, you're from California...I'll rephrase my answer.

In every STATE in the country that has a halfway average EMS system paramedics are allowed to replace trach tubes.

Not a clue about Cali.

 

[Veneficus]

I also think you would have much better luck going through the surgical opening for the trachea than creating your own cric below it. There is a completely disproportionate size of the holes created in the 2 procedures, and the trach is much larger.

completely my error, don't know what I was trying to type.

What I was trying to get at though was if the anatomy above the trach is impaired for whatever reason, just like passing an ET tube, I do not think this would be a viable option.

I think I may have been thinking of a superior trachiotomy, and somehow confused what I wanted to say.

Sorry, again, my fault.

 

[triemal04]

Well...by definition a crich would have to go in a certain spot anyway...

 

[ScubaSteveEMT]

Sh***y medics...

I know that around here (MA), thats an ALS call 100%.

Regardless, however, there was no "handing down" of care by the medics. They left w/ no word to you or your partner. Abandonment. They should have their tickets pulled...around here, OEMS would have their asses.

 

[Bullets]

Just out of curiosity, how far are you from a hospital? If this was in my area, 5min from a Level II, I say screw it, package transport and suction, NOTIFY and get a RT on the phone or at the door

Once I'm done with the call, then I call my Supervisor

Also EMTs in NJ are taught to suction a stoma, at least we are ahead in something

 

[DrParasite]

The medic in the room eventually gets the trach replaced, turns to me and my partner if were ok while she goes and grabs the portable suction, then we can get the PT ready for transport.

this might be the only thing that lets them leave. key word is MIGHT. if the trach is replaced, and returned to a properly functioning position, than it MIGHT be a BLS call (since the airway is no longer compromised).

Regardless, I would have wanted ALS to come with me, even if it was just so if the trach fell out they could put it back in again. the whole M+T and do the stare of life with the BLS crew.