Dislodged trach

[Tigerz_Fan]

So the scenario of the dislodged trach. Meaning a fresh trach (before the first trach change) becomes dislodged or falls out. When reinserted, it enters the pretracheal space, causing bilateral tension pneumothorax, and eventually the patient goes into cardiac arrest if the problem is not recognized.

I was taught in medical school that should a fresh trach become dislodged, you do not reinsert it, you intubate the patient. This is because a fresh trach has not formed stoma yet, and if it is reinserted, it may not be obvious if it is in the trachea or the pretracheal space.

So, I know of 4 cases since 2006 between 3 of the academic centers in my city. Of those cases, many of the staff were not aware that you should never reinsert a fresh trach. After some investigating, it seems that not many people outside of ENT, CCM, and pulm know about this potential disaster.

This has become my soapbox. During one of the cases stated above, I was on the code team. An ancillary staff member (just to leave at that, so no knocks on anyone) outright argued with me during the code because he wanted to reinsert the trach. After the code was finished, I discussed the case with him, and he had said that he never heard of that. I've started asking around, and I have come to realize that it is not a well-known complication. Now I give a monthly lecture to educate on the complications of dislodged trachs. Maybe hoping to save a patient or two...

I was interested to know if any of you have encountered this problem or even seen a few cases.

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[JayneCobb]

I was interested to know if any of you have encountered this problem or even seen a few cases.

At my hospital, most of the surgeon's leave sutures in the trach for 48 hours so that should it fall out, you can pull and lift the trach up for better visualization of the trach as you put it in. In the surgical suite when the sugeon's were showing me wht they do for their trachs, it seemed like it would be very easy to just grap the sutures and lift up to replace the trach, but I've not seen any studies looking at that technique.

We've only had a new trach fall out once, but the only option we had was to replace the trach due to the pt's family being firm in their DNI for him.

 

[Winged Scapula]

I was trained to do what Jayne Cobb suggests and not to take the sutures out until the first trach change (which is always > 48 hours).

I have had trachs dislodged (although not in first 48 hrs as I recall) and I was trained to pull up on the retention sutures, place a red rubber cath into the trachea and then Seldinger in the new trach under direct visualization, then remove red rubber. Have done it several times in this fashion successfully.

 

[Tigerz_Fan]

I'm still unclear as to what happened in the case I saw. I know it was only about 36 hours post-procedure. The staff were cleaning the trach site and somehow the trach dislodged. When I arrived to the room, the trach was lying at the patient's shoulder. When I looked at the trach site I didn't see any stay/retention sutures that I could use to my advantage.

 

[HomerSD]

Your statement about never replacing a fresh trach needs some qualifying. The problem is not advancing a trach in a fresh site, rather it's doing so without direct visualization or some sort of tube changer in place. I've salvaged some trachs by advancing the trach over a bronchoscope that's sitting above the carina. I've used Winged's technique of the red robin, although we have rigid tube exchangers in our code carts and they seem a little easier to use.

Having said all of that, if the pt is in extremus or if I'm unable to get a bronchoscope, I'll just intubate from above. Otherwise, if I have time, I'll try to salvage the trach while getting ready to intubate.

 

[Tigerz_Fan]

Your statement about never replacing a fresh trach needs some qualifying. The problem is not advancing a trach in a fresh site, rather it's doing so without direct visualization or some sort of tube changer in place. I've salvaged some trachs by advancing the trach over a bronchoscope that's sitting above the carina. I've used Winged's technique of the red robin, although we have rigid tube exchangers in our code carts and they seem a little easier to use.

Having said all of that, if the pt is in extremus or if I'm unable to get a bronchoscope, I'll just intubate from above. Otherwise, if I have time, I'll try to salvage the trach while getting ready to intubate.

You're right, I guess I need to be more specific.

The case I am presenting was a patient with a dislodged trach, who was actively coding, and no bronchoscope available. So, in that situation, to intubate from above to establish an airway is likely the best option.

Also please realize that I am presenting this case from the point of view of a medicine resident on night float and captain of the code team. Medicine residents are not taught the techniques you guys are mentioning. And there is no fellow present in the middle of the night.

Actually to be honest, I've done the max number of rotations in the ICU allowed by ACGME, and no one ever taught the techniques you describe. This seems to be reserved for the fellows and surgeons.

Right now my goal is to teach the residents what to do in an emergency, and then page the more experienced people.

 

[Arch Guillotti]

I was taught to pull "up and out" on the sutures.

Is a trach no longer considered "fresh" after 48 hours?

A while back I had to take about a 7 day old trach out in the OR. I had to exchange it for something cuffed so that we could effectively deliver positive pressure ventilation for a laparoscopic procedure.

Everything went fine but it was a little nerbe racking. Normally I swap out trachs that have been there awhile.

 

[Winged Scapula]

Trachs aren't "freshness stamped" so I do not know when they are no longer fresh, either!

 

[Tigerz_Fan]

Trachs aren't "freshness stamped" so I do not know when they are no longer fresh, either!

Looking back at my post I guess it does read like I refer to a piece of fresh meat! I should stop posting post-call!

Anyway, refering to "fresh" trach seems to be a term our critical care and ENT teams use at our VA. It (very broadly) refers to trachs before the first trach change.

 

[SLUser11]

You're right, I guess I need to be more specific.

The case I am presenting was a patient with a dislodged trach, who was actively coding, and no bronchoscope available. So, in that situation, to intubate from above to establish an airway is likely the best option.

Also please realize that I am presenting this case from the point of view of a medicine resident on night float and captain of the code team. Medicine residents are not taught the techniques you guys are mentioning. And there is no fellow present in the middle of the night.

Actually to be honest, I've done the max number of rotations in the ICU allowed by ACGME, and no one ever taught the techniques you describe. This seems to be reserved for the fellows and surgeons.

Right now my goal is to teach the residents what to do in an emergency, and then page the more experienced people.

My question for you: While you were arguing with the ancillary staff member over the blind one-liner "Do not replace a fresh trach," was the coding patient dying?

I think the point here is that this topic is a grey area, and is situation dependent. I think the most important thing is to re-establish the airway in the fastest way possible, since the patient is coding. Maybe someone should be trying to intubate while another person is trying to re-cannulate the trachea through the neck.

Re-inserting a trach is not an advanced technique reserved for fellows and surgeons. In your case, it may have been a common sense way of re-establishing the airway.

I definitely don't think you should have some soapbox where you're trying to teach more residents your blind rule. It may lead to a patient dying without an airway because the resident running the code knows that you just plain don't reinsert a fresh trach......


Also, the tracheostomy itself can be extremely variable, open or percutaneous, with or without stay sutures, so there's no absolute rule there either.....

 

[neutropeniaboy]

Over the years, I've learned a few things about tracheotomies. Partly based on what was taught to me and what I've learned the hard way.

1. Open v. percutaneous trachs: I really don't get excited about the debate anymore. Whatever is the best way to treat the patient by the most qualified physician. However, if you are doing percutaneous trachs as an intensivist, you had better know how to deal with the complications.

2. Any surgeon or intensivist who does not suture the tracheostomy flanges to the neck is a fool. I've seen sutured trachs dislodge, but of all the dislodged trachs I've seen, the vast majority were fresh and NOT sutured to the neck. I always suture the trach to the neck and use a tie, not a Velcro strap.

3. If you're doing open trachs, do a cartilage flap and leave retention sutures.

4. I have used double lumen and single lumen tracheostomies. I don't think there's a big difference in terms of plugging when properly managed. If, however, the ICU or floor staff is notorious for poor trach management, use a double lumen tracheostomy (e.g., Shiley).

5. If the trach falls out, put it back in. It's faster than intubating, and the tube is right there. The problem I see is when people try to insert a tracheostomy appliance without the obturator. I insist that the obturator be taped over the head of bed and that a back-up trach be on the ventilator unit so it can be easily placed when necessary. But, if you are having trouble placing the trach, make sure you have someone working on intubating the patient.

6. A #6 ETT works fine as a temporary trach when in an emergent situation. They should be handy as well by the bedside.

7. Everyone who does not perform tracheotomies needs an inservice on trachs. If you don't have one, ask your local ENT or surgeon to give one.

 

[Tigerz_Fan]

My question for you: While you were arguing with the ancillary staff member over the blind one-liner "Do not replace a fresh trach," was the coding patient dying?

I think the point here is that this topic is a grey area, and is situation dependent. I think the most important thing is to re-establish the airway in the fastest way possible, since the patient is coding. Maybe someone should be trying to intubate while another person is trying to re-cannulate the trachea through the neck.

Re-inserting a trach is not an advanced technique reserved for fellows and surgeons. In your case, it may have been a common sense way of re-establishing the airway.

I definitely don't think you should have some soapbox where you're trying to teach more residents your blind rule. It may lead to a patient dying without an airway because the resident running the code knows that you just plain don't reinsert a fresh trach......


Also, the tracheostomy itself can be extremely variable, open or percutaneous, with or without stay sutures, so there's no absolute rule there either.....

You know when I posted this, I knew someone would have something nasty to say. You were not in that room, so you have no right.

For your information, the staff was trying to replace the trach when I arrived to the room. For your information, the STAFF was yelling at me as I tried to establish an airway from above. Airway from above could not be established, so of course we tried to reinsert the trach at that point. And, that could not be established either, it kept slipping in anterior to the trachea. Don't even say I should have paged others. In the middle of the night, pulm, anesthesia, surgery, and ENT are not in-house at this hospital. I had someone page immediately, but when they arrived, it was too late. Body habitus and anatomy were all working against us.

And no soapbox? You tell me why not. 4 patients in 3 major academic institutions have died because of a malpositioned trach. They died because the code team reinserted the trach instead of intubating. In my opinion, that is 4 too many.

What is the point on working on both airways at once? Establish the upper airway to stablize the patient, then work on the trach in controlled conditions. You still may not know where the end of that trach is. If an upper airway cannot be established, then reinsert the trach.

 

[Tigerz_Fan]

Over the years, I've learned a few things about tracheotomies. Partly based on what was taught to me and what I've learned the hard way.

1. Open v. percutaneous trachs: I really don't get excited about the debate anymore. Whatever is the best way to treat the patient by the most qualified physician. However, if you are doing percutaneous trachs as an intensivist, you had better know how to deal with the complications.

2. Any surgeon or intensivist who does not suture the tracheostomy flanges to the neck is a fool. I've seen sutured trachs dislodge, but of all the dislodged trachs I've seen, the vast majority were fresh and NOT sutured to the neck. I always suture the trach to the neck and use a tie, not a Velcro strap.

3. If you're doing open trachs, do a cartilage flap and leave retention sutures.

4. I have used double lumen and single lumen tracheostomies. I don't think there's a big difference in terms of plugging when properly managed. If, however, the ICU or floor staff is notorious for poor trach management, use a double lumen tracheostomy (e.g., Shiley).

5. If the trach falls out, put it back in. It's faster than intubating, and the tube is right there. The problem I see is when people try to insert a tracheostomy appliance without the obturator. I insist that the obturator be taped over the head of bed and that a back-up trach be on the ventilator unit so it can be easily placed when necessary. But, if you are having trouble placing the trach, make sure you have someone working on intubating the patient.

6. A #6 ETT works fine as a temporary trach when in an emergent situation. They should be handy as well by the bedside.

7. Everyone who does not perform tracheotomies needs an inservice on trachs. If you don't have one, ask your local ENT or surgeon to give one.

Great post, thank you!

I do think the best thing would be an in-serivce for all residents. And hence, the soap box!

 

[SLUser11]

You know when I posted this, I knew someone would have something nasty to say. You were not in that room, so you have no right.

Sorry I hurt your super-sensitive feelings, but there's nothing nasty about what I posted. I simply stated that your "never reinsert a fresh trach" mantra was wrong. It wasn't to insult you....it was to prevent you from training an army of residents the wrong techniques.

For your information, the staff was trying to replace the trach when I arrived to the room. For your information, the STAFF was yelling at me as I tried to establish an airway from above. Airway from above could not be established, so of course we tried to reinsert the trach at that point. And, that could not be established either, it kept slipping in anterior to the trachea. Don't even say I should have paged others. In the middle of the night, pulm, anesthesia, surgery, and ENT are not in-house at this hospital. I had someone page immediately, but when they arrived, it was too late. Body habitus and anatomy were all working against us.

And no soapbox? You tell me why not. 4 patients in 3 major academic institutions have died because of a malpositioned trach. They died because the code team reinserted the trach instead of intubating. In my opinion, that is 4 too many.

A couple things bother me about this. First of all, you try to argue that intubation is the superior (and only) option, then admit that you failed at intubating the patient. After you failed to intubate the patient, what do you suggest as the next move? Just skip A and start on B and C?

Secondly, you refer to your hospital as a "major academic institution," then say there aren't any doctors available that can successfully intubate or trach a patient.


I say "no soapbox" because you have a poor understanding of the situation and how to solve the problem, so I don't think you should espouse your philosophy to your co-residents.

I absolutely believe that 4 people dying is a tragedy. But, they didn't die because someone broke the well-known 11th commandment "Thou shalt not re-inserteth a fresh trach." They died because there wasn't a competent physician available to establish an airway. I have no problem with you getting on a soapbox and talking about that. Maybe they'll get some anesthesia or surgical coverage for the late nights.

What is the point on working on both airways at once? Establish the upper airway to stablize the patient, then work on the trach in controlled conditions. You still may not know where the end of that trach is. If an upper airway cannot be established, then reinsert the trach.

You answered your own question here with your earlier words. You work on both airways at once because neither way is fail-proof, and you're trying to get an airway as fast as possible.


Also, the real take home message here is that if you fail to intubate, and you can't reinsert the tracheostomy, you should slice that patient's neck clean open. If you find it technically easier, you can do an emergency cricothyroidotomy (although honestly I'd just filet the neck open and reinsert through the tracheotomy if possible). If the patient is going to die without an airway, make a big old longitudinal midline incision, slice open the trachea, and jam an airway in there.



Again, this post isn't aimed at insulting you, although I know it's a necessary evil......if you want to make an omelette, you have to break a few eggs.

If you are uncomfortable in a situation, you should really try to get someone there as fast as possible that can handle the problem. You shouldn't try to intubate, then try to re-trach, then when that doesn't work, call the anesthesiologist. If you can't intubate well, you should call anesthesia immediately when you get there.

 

[Tigerz_Fan]

Yes, I admit I failed to intubate this patient. And I have lived with that every day since. This was my one and only airway I could not establish. It has nothing to do with comfort level. I am very comfortable with typical airways. I am not trained (yet) in difficult airways. Like I said, anatomy and habitus were working against me. I had someone page every single person I could think of. Too late by the time help arrived.

I should define institution. This is a hospital that 2 major academic institutions cover. And I'll state it plainly. A VA hospital. Does that help? We are using this case to try to pull in back-up at night.

The other cases I am researching. And did not happen at the VA. All I want to do is make people aware of what can happen with a trach inserted in the wrong place. That is all. To make people think that if a trach is reinserted, and is hard to bag, that chances are it may not be a mucous plug.

 

[proman]

One point to consider is that people don't die because they don't have an "airway". They die because they are not being oxygenated. This can be accomplished in many people who are difficult to intubate. How? With a bag-valve-mask aka Ambu bag. It might help you to review the ASA difficult airway algorithm. Masking patients is the single most important airway technique and saves people's lives, not intubation by any technique. Certainly there are rare patients who cannot be adequately masked, and even fewer who are "can't ventilate, can't intubate".

 

[dragonfly99]

SLUser,
I do think that the response you wrote comes across as condescending and kind of aggressive.

I get your point about there being no hard and fast rule about not reinserting a fresh trache. I think there aren't a lot of "hard and fast/absolute" rules in medicine, but I think tigerz' point was that a lot of people are unaware of possible complications of reinserting a fresh trache.

I am glad tigerz posted this, as I think it's an important topic.

The discussion above by the surgeons about sutures, etc. is above my level of knowledge...as an IM resident I really got almost no training about what to do with a trache...did learn some on the job, though. Luckily never had to deal with a dislodge trache alone, though lots of incidents with plugged traches, etc. that needed suctioning.

I think that IM residents are often put into difficult situations at night vis a vis "code" situations. This is because at many teaching hospitals they are the code team for all patients, including many they do not know, have no signout/medical history for, and who may have a lot of non IM-related issues (such as recent surgery, traches, etc.). Also in many teaching hospitals, intubation is not a skill that is well taught, or taught much at all, to IM residents. Due to liability concerns, many hospitals would like that most or all intubations just be done by anesthesiology or pulmonary/critical care fellows. This is during the day when things are in a controlled situation. However, when you are there at night, usually with just some medicine intern with you, then you are running to every code and guess what, people expect you to fix everything, including the airway. So it can be a problem.

I agree with the excellent comment above about the possibility of just bagging the patient if you can. However, some patients have upper airway issues and that is why they got the trache - in such a situation bagging the patient would not really work. Interestingly, I recently retook ACLS and there was more emphasis on using an LMA as an option to establish the airway. I can see why, because honestly it's a lot easier to use...I know there are issues with those, but as opposed to struggling with an intubation, I'll be tempted to try to use an LMA if I can't just bag the patient until anesthesia gets there.

I think the VA should pay to have a CRNA or anesthesia resident in house at night.

 

[Tigerz_Fan]

One point to consider is that people don't die because they don't have an "airway". They die because they are not being oxygenated. This can be accomplished in many people who are difficult to intubate. How? With a bag-valve-mask aka Ambu bag. It might help you to review the ASA difficult airway algorithm. Masking patients is the single most important airway technique and saves people's lives, not intubation by any technique. Certainly there are rare patients who cannot be adequately masked, and even fewer who are "can't ventilate, can't intubate".

Completely agree. The first thing always taught in airway management is to bag the patient. Unfortunately, bagging didn't work in this case.

To further clarify the case: I arrived to the room seconds after the code was called. The patient was being bagged when I arrived. About a minute into the bagging as I was setting up airways and examining the trach site for possible reinsertion, we lost a pulse. Another IM resident arrived, and ran the code while I worked on the airway, and the RT worked on the trach. Nothing worked.

Thank you Dragonfly, LMA is always an option if it available, as is a combitube. In this case, not so because neither were available.

As an update a few good things are going to result from this. We may get back-up at night. An in-service is being held monthly for all staff regarding trach care. Obturators are now at bedside for all our trach patients (thank you neutropenia boy, I got that one this morning). Combitubes are now on the crash carts and in the ICU at all times. LMAs are on backorder.

 

[dragonfly99]

what the hell...
they should have LMA's in the crash cart too. Always better to have more options.

 

[dragonfly99]

Remember, you didn't kill the patient.
The patient's disease (whatever caused him to need the trache, probably) killed the patient.

 

[proman]

I'm curious as to why you couldn't ventilate and also why the patient had a trach. It's very rare to have to do a trach for a difficult airway. A cric is a different story. There's always the option of doing a fiberoptic placement of a tube through the neck.

Anyone responsible for securing an airway should be proficient with the difficult airway algorithm. LMA is just one option.

 

[dragonfly99]

It's one thing to know an algorithm, and a whole other thing to be able to secure an airway in the middle of the night in a code situation. Remember, in IM we have to know pretty much everything (except surgery and peds stuff) and it's really impossible to be an expert on everything, especially when certain things such as securing an airway are not really taught in IM residency to any significant degree.

 

[dragonfly99]

And I'm curious about what you mean by it being rate to put in a trache for a difficult airway. It seems like I've seen some put in for that exact reason...

 

[Tigerz_Fan]

I'm curious as to why you couldn't ventilate and also why the patient had a trach. It's very rare to have to do a trach for a difficult airway. A cric is a different story. There's always the option of doing a fiberoptic placement of a tube through the neck.

Anyone responsible for securing an airway should be proficient with the difficult airway algorithm. LMA is just one option.

I am not sure if you are ER, anesthesia, or surgery. But I am an IM resident. Which means we are taught squat about airways in general, and nothing about difficult airways.

As I said before and I will say again, this patient's habitus and anatomy were working against me. He was trached for long-term ventilation. He was 400lb with the shortest neck I've ever seen. The trach site was less than 24 hours old. Because of the massive amount of tissue in his neck, it was impossible to reinsert the trach. Because of the brand-new trach, everything I saw when I tried to intubate was edematous as all hell. And (!) no back up, no back-up equipment. No LMA, no combitube. The fiberoptic scope was nice and locked away in an OR suite and anesthesia is not in-house at night. Don't even mention the bronchoscope, that is locked away also. And when on-call back-up arrived from home, the patient had already died.

And I will say again, this was the only airway that I could not secure. I have almost 100 intubations, very good for a medicine resident. This was the only one I have attempted and missed.

 

[carrigallen]

And I will say again, this was the only airway that I could not secure. I have almost 100 intubations, very good for a medicine resident.

What kind of hospital was this, like a community VA in Wyoming?

 

[pillowhead]

What kind of hospital was this, like a community VA in Wyoming?

i am an anesthesia resident but i did my internship in mostly internal medicine. at our major, regional VA, there was no one in house at night except a medicine PGY 1, 2, and 3. RTs there were fairly proficient at intubating but intubating normal airways vs. difficult airways or airways that have been recently manipulated is a totally different situation. The situations described in this thread could easily happen to anyone...many large hospitals don't have in house anesthesia at night. And while in house surgery is nice, I've seen general surgeons fail at an emergency invasive airway on a a complicated ENT patient at the bedside. (and i've never seen them successfully intubate outside of a controlled situation in the OR which makes it a pain when they try to intubate before i get there leaving a bloody mess for me)

crap can and does happen when it comes to the airway, and when it happens, it happens extremely fast. i'm shocked there were no LMAs in your code or airway box available. did you have oral and nasal airways? even if the intubation was impossible, LMAs are fairly easy to use and hopefully the RT should be familiar enough with them to use them successfully. i've seen patients rescued with the LMA who were otherwise cannot ventilate, cannot intubate. very scary stuff.

most patients can be masked--even the most morbidly obese, but it's not easy. you need an oral airway, 2 nasal airways (all of which must be the right size...most people grab stuff that's too small), and a strong person pulling up the jaw from both side with both hands as much as they can. and i mean pulling hard as hell. then you need someone else to bag. it may not be easy, but it can buy time for a while. the trouble is, prolonged masking will eventually fill the stomach with the air. then you get emesis and aspiration and an even harder airway to deal with.

 

[proman]

I am not sure if you are ER, anesthesia, or surgery. But I am an IM resident. Which means we are taught squat about airways in general, and nothing about difficult airways.

I am an anesthesia resident. You were placed in a situation that you lacked the training for (emergency airway management). That is not your fault, but the medical institution's and your training program. Maybe some good can come out of the patient's death by changing the education and backup of the medicine residents

As I said before and I will say again, this patient's habitus and anatomy were working against me. He was trached for long-term ventilation. He was 400lb with the shortest neck I've ever seen. The trach site was less than 24 hours old. Because of the massive amount of tissue in his neck, it was impossible to reinsert the trach. Because of the brand-new trach, everything I saw when I tried to intubate was edematous as all hell. And (!) no back up, no back-up equipment. No LMA, no combitube. The fiberoptic scope was nice and locked away in an OR suite and anesthesia is not in-house at night. Don't even mention the bronchoscope, that is locked away also. And when on-call back-up arrived from home, the patient had already died.

Kheterpal (Anesthesiology April 2009) reviewed ~53,000 anesthetics and found: Over a 4-yr period from 2004 to 2008, 53,041 attempts at mask ventilation were recorded. A total of 77 cases of impossible mask ventilation (0.15%) were observed. Neck radiation changes, male sex, sleep apnea, Mallampati III or IV, and presence of beard were identified as independent predictors...Nineteen impossible mask ventilation patients (25%) also demonstrated difficult intubation, with 15 being intubated successfully. Twelve patients required an alternative intubation technique, including two surgical airways and two patients who were awakened and underwent successful fiberoptic intubation.

To repeat, surgical airway is exceedingly rare in patients (2/53,000).

Others have identified obesity, being edentulous, neck circumference and age to be additional risk factors. You likely have not had the training to be considered proficient at mask ventilation. Risk factors for difficult intubation are different. Unfortunately, you, and others, are placed in situations where this may be the one life-saving skill the patient needs. The ASA difficult airway algorithm is the standard of care for anyone managing an airway. Direct laryngoscopy is just one part of airway management (the only one most non-ENT, non-anesthesia physicians are familiar with). This is likely the best approach at getting your program to provide appropriate training (we have simulation, cadaver labs, mock codes etc).

And I will say again, this was the only airway that I could not secure. I have almost 100 intubations, very good for a medicine resident. This was the only one I have attempted and missed.

I don't mean to sound harsh, but the system you describe present at that hospital is perfectly designed for the outcome that happened and shouldn't be a surprise. In every ICU we have a difficult airway cart (includes LMAs, flexible fiberoptic bronch, crich kit etc). On every patient floor we have a cart (includes operating laryngoscopes, rigid bronchoscopy etc) set up for ENT or trauma/general surgeons. We also have attendings go to codes (not common at other institutions even when they are in house). 100 intubations is just barely enough to be considered proficient at normal, easy appearing airways. And finally, I hope it's now apparent that intubation does not equal airway management.

Here are the ASA Practice Guidelines for Management of the Difficult Airway:
http://www.asahq.org/publicationsAndServices/Difficult%20Airway.pdf

I sincerely hope this experience will ultimately lead to improving future resident education and elevating the standard of care in this hospital.

 

[Tigerz_Fan]

Thank you for the article.

Totally agree that 100 tubes is barely enough experience for normal airways. And definitely should not be the one attempting the difficult airway. Hence the need for backup.

 

[JayneCobb]

I highly recommend the Difficult Airway course for anyone who might be running codes. While I'm still not an airway master, I definitely walked away with a perspective and a base understanding that a ET tube isn't the only means to keep a pt alive. Airways use to scare me, I'm much more calm during resp distress cases than I was prior.

Not long after I got back from the airway course, we had a copd gomer on the floor who suddenly worsened on the floor. The intern I had that night was an ED intern who'd already done 20 or so intubations without any issues, and he missed it, so I get in there with and the pt had a grade 3 view and with cric pressure I could see the very bottom of the cords. I grabbed a bougie out of the cart and went to throw it in and it turned out that it was a bougie that didn't hold any bends so it would not angle up to pass in the cords, so I backed out and we bagged the pt for a bit while I got set up with an intubating LMA and then got that in. The point of the story isn't that oooooo look at me, I'm a master of a difficult airway because I went to a 2 day course, I'm not. But the biggest thing I took away from the course is there are almost always another option to get the job down as long as you what your options are.

Like Tiger, my hospital does not have in-house gas coverage at night, I don't have access to a bronch but we do have a McGrath video laryngoscope (which all of the residents here hate) and a glidescope in the ED and OR.

 

[SocialistMD]

SLUser,
I do think that the response you wrote comes across as condescending and kind of aggressive.

But his point is valid- Tigerz_Fan shouldn't be professing things when s/he doesn't really know what s/he is talking about.
Examples:
1.

They died because the code team reinserted the trach instead of intubating.

This is a bold and flawed statement. First off, they didn't actually reinsert the trach or the patient would have been oxygenated. It would be more grammatically correct to say "They died because the code team attempted to reinsert the trach instead of intubating," but that's just semantics. For the one case in which s/he was actually present, it wasn't the attempt to reinsert the trach that led to the patient's demise, it was the inability to secure the airway, as was the case in all of the other cases. Tigerz_Fan followed his/her own algorithm and attempted to intubate the patient from above, couldn't, and the patient died. To me, Tigerz_Fan's algorithm didn't work in the one situation in which s/he was involved, so it doesn't seem like something that should be taught as doctrine, particularly by Tigerz_Fan. It is plausible that in the other three cases, endotracheal intubation wouldn't have been possible, either. If it was never attempted, one can never know, so it isn't a logical conclusion to draw that it was the cause of the patients' deaths.
2.

But I am an IM resident. Which means we are taught squat about airways in general, and nothing about difficult airways.

I don't think I really have anything to add to this one; it pretty much says it all itself. How can you profess the rules of managing difficult airways (which I would consider a fresh trach to be) when you openly admit you aren't taught anything about them?

Look, I'm not attacking Tigerz_Fan, either. I just find it suspect that someone who later admits s/he doesn't really know anything about the subject feels it is his/her place to lecture people about how to do something. I think Tigerz_Fan has been very proactive about addressing a systems-issue and that good will come from this patient's unfortunate end. I think this discussion has taught many people a great deal about trachs and tracheostomy care. I also think another lesson that can be learned in this case is to not lecture someone when you don't really know what you're talking about, as that can cause further bad outcomes as SLUser explained.

As for the stay sutures, it makes me almost positive that the patient had a percutaneous trach (Blue Rhino or the like), as I have never done nor seen an open trach without stay sutures, especially in a patient with a short, thick neck. The percutaneous technique also explains why the trach likely fell out, as they are usually designed for "one size fits most" and the cannula itself was likely not long enough for the patient's thick neck. I guess another lesson from this case is patient selection and knowing that not everyone is a candidate for a percutaneous trach. That darn hammer-nail concept rears its ugly head yet again...

 

[Tigerz_Fan]

My wording may not be to your liking, but it is not a flawed statement. All three patients had proven by autopsy bilateral tension pneumothorax, and two had pneumomediastinum due to dislodged trachs. The autopsy on my case is still pending. But yes, intubation was never attempted, so we will never know what the outcome could have been.

You completely miss the point of my first post. I want to teach residents about a deadly coomplication of a dislodged trach. THAT IS ALL. So they think about it before attempting to reinsert the trach. That there are other options instead of just reinserting the trach.

Why am I wrong to want to make residents aware of a complication that can kill a patient???

I have never professed to being an expert. Maybe that is why I am working with our ENT department to create a presentation.

And no, it was not a perc trach. End of that discussion.

You may claim that you are not attacking me, but it sure seems that way. Instead of stating the obvious (that I am not an expert), why don't you discuss why in the hell institutions will not train their code teams in difficult airway management? And if they will not train their residents, then why not someone on the code team at all times, who is trained on difficult airways, like maybe anesthesia (such as it is in the other hospital where I work).

 

[SocialistMD]

So, what you are telling me is that the tension pneumos that resulted from the failed attempts at recannulating the tracheostomy that killed those patients (B on the ABC's) and not the lack of an airway? Interesting.
Your first post said your "soapbox" was to tell people they shouldn't try to reinsert a fresh trach, as it is something one "should never do."
That just isn't true; you reclaim the airway any way possible. Thus, your soapbox is incorrect, as it comes from inexperience and a lack of understanding of the management of difficult airways, as pointed out before.
In your learning about difficult airway and trach management since this incident, do you still believe it to be true that one shouldn't at least try to reinsert the trach in an attempt to reestablish an airway?
If so, you are being stubborn. It is an acceptable practice, especially when using a red-rubber catheter to pass it over.

I don't know why you'd expect me to discuss the members of a code team because I don't understand myself why they wouldn't put someone who knows what s/he is doing on the code team.
Every code team at our hospitals have at the very least a general surgery resident (VA), and at our main hospital, there is always someone from ansethesia.

 

[Tigerz_Fan]

So, what you are telling me is that the tension pneumos that resulted from the failed attempts at recannulating the tracheostomy that killed those patients (B on the ABC's) and not the lack of an airway? Interesting.
Your first post said your "soapbox" was to tell people they shouldn't try to reinsert a fresh trach, as it is something one "should never do."
That just isn't true; you reclaim the airway any way possible. Thus, your soapbox is incorrect, as it comes from inexperience and a lack of understanding of the management of difficult airways, as pointed out before.
In your learning about difficult airway and trach management since this incident, do you still believe it to be true that one shouldn't at least try to reinsert the trach in an attempt to reestablish an airway?
If so, you are being stubborn. It is an acceptable practice, especially when using a red-rubber catheter to pass it over.

I don't know why you'd expect me to discuss the members of a code team because I don't understand myself why they wouldn't put someone who knows what s/he is doing on the code team.
Every code team at our hospitals have at the very least a general surgery resident (VA), and at our main hospital, there is always someone from ansethesia.

I am aware of the ABCs of ACLS.

I presented you the autopsy reports. I agree that the airway should be extablished by all means, But, they need to be aware of potential complications. THAT IS MY POINT. That if it is hard to bag, chances are it is not a mucous plug. And to use the CO2 detector. In the cases I have looked through, they continued to bag the patient even though it was difficult, they blamed it on a mucous plug. And noone thought to use the CO2 detector.

Enough of your statements about people not knowing what they were doing. You've made your opinion of me very clear. It's unnecessary. Not everyone's training is the same, and not every hospital is run the same. I would love for surgery and anesthesia to be at all of our codes, but it won't happen. We medicine residents get stuck with the job for some reason. Which means we are fantastic at handling the cardiac and "medicine" aspects of a code, but when it comes to dealing with a surgical issue, we are screwed. You have no right to accuse someone of not knowing what they are doing when in fact not a single thing about trachs is part of their training. You are a surgery resident, if you called me for a consult for a non-STEMI, I would not tell you that you didn't know what you were doing. I would assume that you did not know how to treat this life-threatening condition because it wasn't part of your training.

So, please, back off.

 

[SocialistMD]

Excellent point. That's proably why I never get on my soapbox about the management of NSTEMIs to other people, but then again, that is my point.

 

[Tigerz_Fan]

Excellent point. That's proably why I never get on my soapbox about the management of NSTEMIs to other people, but then again, that is my point.

I did state before that I am working with our ENT department to put together a presentation. I also have discussed this with several surgery residents.

So, can we leave it at that?

 

[SocialistMD]

You weren't when you first got on your soapbox after your first code, but you don't seem to see the difference so, yes, we can drop it.

 

[Tigerz_Fan]

You weren't when you first got on your soapbox after your first code, but you don't seem to see the difference so, yes, we can drop it.

Yes, I do see the difference, that is why I am telling you that I am working with other departments. But, I have been working with them all along. No one had brought it up except you, so that is why it just came up.

If you do feel that I have no place initiating this at my hospital, then that is your opinion, and you are intitled to it. I however, do not see a problem with a multi-departmental approach to this, which is what I am working on.

So, I guess we will just agree to disagree.

Take care...

 

[SocialistMD]

This has become my soapbox. During one of the cases stated above, I was on the code team. An ancillary staff member (just to leave at that, so no knocks on anyone) outright argued with me during the code because he wanted to reinsert the trach. After the code was finished, I discussed the case with him...

Let's be honest here, you didn't call an ENT and start working with him/her prior to this conversation.
That's all I have to say on the subject. I wish you luck on your multidisciplinary approach to teaching people how to deal with decannulated trachs. I'm sure it will save lives, which is the ultimate goal.

 

[Tigerz_Fan]

Let's be honest here, you didn't call an ENT and start working with him/her prior to this conversation.
.

You are being completely ridiculous, enough already. You have stated your opinion about something you have no evidence to even draw a logical conclusion on, and now are reaching even farther. So, please, do what your posts say, and let the subject drop. Enough of the unwarranted accusations.

And I'm done here, I will not post any replies to your posts unless you decide to be professional.