Trach tube safety in Georgia nursing homes

A tracheostomy (trach) tube is a curved tube inserted into the trachea for the purpose of providing air to the patient. A trach tube requires specific upkeep and care to remain safe for the patient. In today’s episode, nursing home abuse lawyers Rob Schenk and Schenk Firm discuss common safety issues surrounding trach tubes in nursing home residents with Michelle Glower, RN and legal nurse consultant.

Schenk: Hello out there. I’m Rob Schenk.

Smith: And I’m Schenk Firm.

Schenk: And we are your hosts of the Nursing Home Abuse Podcast. Very interesting episode today for you. We’re going to be talking about trach tubes, specifically trach tube safety for residents of long-term care facilities in the state of Georgia. And we’re not doing it alone. We have an extra special guest. Her name is Michelle Glower. She’s a registered nurse. Will, tell us a little bit about Michelle.

Smith: Yeah, so Michelle is from Chicago, Illinois, the Lincoln Park area. She earned her associate degree in nursing from Harry S. Truman Community College, a bachelor’s degree in nursing from Loyola University of Chicago and a master’s in nursing from St. Xavier University of Chicago. She has over four decades of nurse experience in emergency nursing and nursing administration. She currently is a clinical instructor teaching in both the associate degree problem and bachelor’s program at Keiser University – Sarasota, Florida. So we are very privileged to have her and her expertise with us today.

Schenk: That’s right. Michelle from Lincoln Park, welcome to the show.

Michelle: Great, thank you for having me.

Smith: So one of the issues that we deal with often is the reason we brought you on here because you’re an expert in this area is tracheotomies and trach tubes. We will often have residents that have had an accident or because of some sort of disease end up having a trach tube placed in their throat and there are all kinds of issues related to the care of that and the maintenance of that. But at the very beginning, can you just tell us what a trach tube is and kind of explain it?

What is a trach tube?

Michelle: Sure, I’d be happy to. A trach tube, also known as a tracheotomy where they make a surgical incision in the front of your neck to provide an opening into the windpipe so they can put a tube in, and this allows air to enter into the lungs. And it’s used as a temporary device and it can also be used as a permanent device. It depends on the situation of why they’re needing a trach tube to begin with. So it helps people who need to breathe or be on a ventilator, or if they’ve been on a ventilator for greater than two weeks, you have to then create this opening in their neck to provide an airway.

Smith: And it goes into the lungs, right? It’s from the airpipe into the lungs?

Where does the trach tube go in the body?

Michelle: Actually it doesn’t. It’s a short tube, and when they create the hole in the front of your neck, it’s below the vocal chords. And they put a plastic tube to keep the opening open. This way, the air goes right from your windpipe into your lungs. So the tube is not in your lungs.

Smith: Ah, I got you.

Michelle: Yeah, it’s a very short tube.

Smith: Now are people still able to speak? Are they still able to swallow?

Michelle: Good question. Yes, they can. Yes, and I probably should say yes and no.

Smith: Right.

Can you swallow or speak with a trach tube?

Michelle: You can speak with them, especially with patients who have long-term traches. They do provide them with apparatus that allows them to cover their trach to be able to force the air out of their mouth to create sound. And again, that’s for patients who are not fresh tracheotomy patients. They’re usually long-standing and they are able to provide them with, like I said, some sophisticated methods to cover the trach and be able to force words.

They also can eat. They have to be – one of the risks is you don’t want them to get any food into the trach because it could cause what we all an aspiration – to choke – because that airway is right into your windpipe, and I don’t know if this has ever happened to you that you actually swallowed it and it went down the wrong way and you’re choking. Well that would be the same thing if food got into the front of the trach. So there is a way that patients can have food when they have a trach, so it’s not all doom and gloom when you have one.

Smith: I got you. It seems to me that it’s any time you have an opening like that that’s going into your body that even if it’s just a catheter, if you’ve got something that’s going into your body, it’s prone to infection. Are these prone to infection?

Do trach tubes lead to infection?

Michelle: They can be if they’re not properly cared for and cleaned. Especially in the presence of taking care of them in acute care settings or nursing homes where you’re going from one patient to the next. And we know that these healthcare facilities are housed with germs such as MRSA, which is MRSA, c. difficile, all kinds of infections, so you have to – when you’re cleaning the trach, you really have to use a strict precaution to make sure you’re cleaning around the stoma where the surgical incision is, making sure you’re cleaning the inside of the trach when you take out, there’s a tube, a cannula that comes out that has to be cleaned because it gets secretions on it that can form crust. And if you don’t take care of these properly, yes, they can get infected. The patient can get pneumonia, so there are lots of reasons you do need to have strict precautions when cleaning.

Smith: And it always amazes me how people don’t understand how dirty nursing homes can be. I was a CNA for a long time at a nursing home, and after working there, one of the things I’m constantly telling people is, “Listen, if you go visit your loved ones, don’t let your kids just play on the floor.”

Michelle: Yes.

Smith: You have no idea what’s been on that floor the past 30 minutes. But yeah, you’re right. These are places where there’s an increased risk of infection. We hear oftentimes people talking about suctioning. What is that?

What does it mean to ‘suction’ a trach tube?

Michelle: Yes. The patient who has a tracheotomy, they will produce a lot of mucus. And if they’re on a ventilator, they’re not able to expectorate, cough it up and get it out. So even with ones that are not on a ventilator may require some additional assistance in trying to help get that mucus out. And they just can’t get it. We call it a plug. And you really got to get down there with a very thin, pliable tubing and help assist getting that mucus out for the patient. And it helps also to prevent pneumonia, because you have to help get these secretions out.

And so we take a small, pliable, plastic tube connected to the wall suction or maybe a portable suction in some nursing homes that don’t have the sophistication built into the wall. So we go down into the airway with a small tube. It will make them gag and you will provide suction as you’re bringing the tube back up. But prior to suctioning, you have to give them some oxygen because what you’re doing is taking oxygen away from them as you’re bringing the catheter out of the airway and sucking the secretion. So it is imperative that patient’s airway is always clear and free of mucus. So we do that very regularly in nursing homes, hospitals, even when they’re at home.

Smith: Yeah, it sounds like this is a very complicated issue to deal with. What are major concerns that people have with trach tubes or maybe areas where they run into problems?

What are some major concerns with using a trach tube?

Michelle: Sure. One of the biggest problems we see is patients where the tube, the actual cannula comes out, and it would come out either because patients pulled it out or it was not secured properly and maybe a suture fell out or the ties weren’t properly tied around the neck, because we tie part of the apparatus around the neck, and we do change those ties out. They’re like little ribbons and that’s one of the biggest concerns you have because if it’s someone who just had a tracheotomy and they pulled that trach out, that airway could close and that could cause imminent danger to the patient. So you really have to be cautious. You always have to have an extra cannula in the room taped to the head of the bed because in the event that it does get pulled out, you need to reinsert a new one. So that’s our biggest risk that we have with the traches.

Smith: Yeah. A lot of our listeners are individuals with loved ones in nursing care, nursing homes or acute care centers or long-term care facilities, whatever it may be, many of which do have traches for various reasons, whether it’s accidents or, like I said, disease. What are some signs that there might be a problem?

What are the signs of trach tube problems in nursing homes?

Michelle: Are you speaking once they have the trach?

Smith: Yeah, or things that family members need to look out for?

Michelle: Sure.

Smith: Because you know as well as I do that a nursing home, some of them, Georgia is very bad – I’ll just be honest with you – and some of them, you really need to be vigilant on. So what are some things that family members need to take note of when it comes to visiting?

Michelle: Sure. If your family member has a trach, you want to make sure that their airway is clear, meaning that they are able to bring up the mucus. Otherwise, that’s their airway and it needs to be cleared. And they may be taught on how to assist with suctioning their loved ones, and you have to use proper technique in order to do it. If the patient is filled with mucus, it’s going to cause an airway obstruction, so you have to be alert to looking at their color of their skin. Do they look greyish? Do they look cyanotic, like they’re turning blue because they’re not oxygenating? So it’s imperative that the airway’s clear all the time from all of this mucus because that is their windpipe to the world.

And patient’s families are great on being able to be taught how to assist in trach suctioning and to look for symptoms of an airway obstruction or if the trach should fall out, what should they do? They should be trained on those emergency techniques and they can do until the providers arrive. So it’s a risky – it can be very risky if you don’t know what you’re doing.

Smith: And what are some reasons that people end up with trach…

Michelle: Tracheotomy.

What is a tracheotomy?

Smith: Tracheotomy. First of all, for those of us who aren’t nurses, what is a tracheostomy and a tracheotomy?

Michelle: Okay. A tracheotomy is the procedure. That’s the actual surgical procedure. So you are going to go in and have this done – the surgeon would be performing a tracheotomy on you. We refer to them as tracheostomies when we’re speaking in a plural sense – we have multiple patients who’ve had tracheotomies, and we would call them tracheostomies done. It’s kind of interchangeable, but the -otomy is the actual procedure that the surgeon uses as the code for billing, I guess, purposes, and you asked me another question and I forget.

Smith: Oh, you answered it. And the -ostomy is, as you mentioned earlier, the stoma, the actual entrance.

Michelle: Yes.

Smith: Now isn’t this the procedure that I know that I’ve seen on television, in emergency situations, people have had to perform on somebody and it can actually be done?

Michelle: Well let me tell you about that. There is a procedure that paramedics do in the field where you’ll see on TV. It’s called a – as an old ER nurse, we used to call them crikes – it’s a crico-something – I’m not sure if I’m saying it right.

Smith: That’s okay.

What is a cricothyotomy?

Michelle: They do an incision in the neck. It’s not a tracheostomy. It’s a temporary little device. It’s not sterile so that’s just to perform immediate life-saving technique in the field. If somebody were choking on a lifesaver or got a chicken bone stuck in their throat and they had to do emergency crikes, then the paramedics are trained to do that. Then, when they get to the hospital, under sterile technique, they would perform the tracheotomy.

Smith: Ah, I got you. And I looked it up as you were talking about it is called the crike, and for very good reason because the actual term is cricothyotomy, which I can’t imagine is very efficient if you’re in the field and you need to perform one. You probably say, “Hurry up and do a crike.”

Michelle: Right.

Smith: But as far as the reasons, what are some of the general reasons why somebody may have a tracheostomy?

Why would a nursing home resident need a tracheotomy?

Michelle: Sure. Multiple vehicle collisions that resulted in trauma such as a person being paralyzed from the neck down, like a quadriplegic. You will know that Christopher Reeve had a tracheotomy because he had a very high-level neck fracture and he was what we call a quadriplegic. And his neck was fractured at C1-C2, which paralyzes his ability to breathe on his own, and so he was on a ventilator attached to his wheelchair. So we see a lot who are paralyzed with high neck fractures that end up with tracheotomies.

Patients who have had not just like cancer or some form of tumors in their neck may have to have a temporary tracheotomy or patients who certainly who’ve been on a ventilator too long, because what happens is when you’re on the ventilator and there’s a tube going down your throat into your lung, that tube can cause like a pressure ulcer because it’s in there so long laying next to the trach, the windpipe. It can cause a sore. So you’ve got to take that out. But taking it out, the patient won’t be able to breathe, so you perform a tracheotomy and you can hook them up to the ventilator through that stoma, through that trach. So you see that in trauma and you see it in certain diseases, for instance Guillain-Barre syndrome – some patients will end up having to be on a ventilator for any length of time may end up with a temporary trach. Lou Gehrig’s, where they lose a lot of control over their ability to swallow too at the end, may need a trach. All kinds of various reasons, but the major reason is more from trauma.

Smith: I got you. And we have this question here, so I’m assuming we have it for a reason: will anticoagulants affect trach use?

Do anticoagulants affect trach tube use?

Michelle: Oh, good question too.

Smith: Okay, well whoever on our staff came up with this question, we’ll make sure they get a Starbucks gift card.

Michelle: Anticoagulants. First of all, I teach nursing and I instruct every student, when you go into the room, I don’t care what kind of procedure you’re doing, whether it’s starting the IV or taking one out, you’ve got to ask them if they’re on anticoagulants. It makes a difference for just about everything, because if a patient is going in for a trach, there will be minimal bleeding. But if they’re on anticoagulants, it could prolong their bleeding times. And if you don’t know ahead of time that they are on it, the patient could – you have to measure their bleeding times and there’s medication that we can give the patient if their bleeding times are too prolonged so that we don’t have any hemorrhaging when we do the incision, but more importantly, post-operatively, nurses have to look for and be in tuned if the patient is developing a blood clot, which we call a hematoma, near the incision site. And that can grow pretty sizable and impede the airway, so you have to be able to be smart enough to be able to look for those signs and symptoms of a decreased airway from a hematoma that could be forming because when patients are on anticoagulants, they will bleed.

Smith: So what, in general, what are the issues that you see the most with traches then with patients in long-term care settings?

What should a family know about trach tubes in nursing homes?

Michelle: Sure. The requirement to suction them, and unfortunately in nursing homes, the staff, only an RN or LPN can suction the patient. The techs or the aides are not licensed to be able to suction. The staff in nursing homes have a lot of patients, and what I see mostly is the care is – I don’t want to say it’s terrible, but when you’re in a hospital, you have more staff to patients because patients are more acutely ill, but they still are requiring suctioning, so patients will aspirate in nursing homes and then they’ll have to go to the hospital because maybe they weren’t suctioned often enough or maybe they were suctioned and the nurse didn’t do it properly.

There’s a technique and you have to be very skillful and I will also see nurses, when they go down to suction, they’re already putting suction on the tube while they’re going down, and that’s inaccurate. You have to provide the suction as you’re coming out of the airway, not going down into the airway. So these are common errors that you see that can have some devastating results.

Smith: Yeah, it’s unfortunate. It’s something we were talking about in another episode related to the level of skilled nursing care that residents get. Just something that I pointed out and I’ve always thought this – clearly, this does not apply to every RN. You’re an RN, my brother is an RN as well, but I find that the LPNs or at least the RNs like yourself that deal with actual patient handling and that would actually on a regular basis do the suctioning know what you’re doing. The fact that you have an RN there, if he or she has never suctioned somebody, it’s not really going to help you. The same thing – you could have a doctor standing right there, they’ve never suctioned anybody, they’re kind of useless, you know? This is a technique that requires a lot of skill.

Michelle: It does.

Smith: Well this is a fascinating area. It’s unfortunately something a lot of people have to deal with. You mention though some people can have these in permanently?

Can trach tubes be permanent?

Michelle: Yes.

Smith: So you could live the rest of your life…?

Michelle: I’ve seen them. Yes. But they function very well, and I’ve even seen patients, residents coming into the hospital and they don’t even have a trach tube but they have the stoma in place and the hole there because they’ve had it for 30-40 years, and the hole will never close up, and so they’ve got a permanent opening and they use it and they cover it with their hand. I’ve even seen them do that to force air out of their windpipe to make sounds to talk.

You’ve seen those commercials from smoking and the person had part of their throat surgically incised and she’s got a little apparatus, an instrument that she holds up to her neck to formulate sounds so people can hear her when she tries to talk, and that’s from smoking. She has lost her voice box, she has lost part of her throat, I mean it’s horrible what cigarettes alone can cause.

Smith: Yeah, let this be a PSA on the dangers of cigarettes as well.

Michelle: Yeah.

Smith: Growing up, I had a next-door neighbor who had one of those issues who had one of those little, the little vibrating things that she had to put to her throat to make sound. I can’t believe they haven’t advanced it any further in the years…

Michelle: Yeah, it’s frightening to even look at it if you’re not a healthcare provider. Kids can be frightened, even from that commercial. It’s a very scary outcome.

Smith: Yeah, absolutely. Well Michelle, we really appreciate your breadth of knowledge and your expertise in this matter. Go ahead.

Schenk: And Michelle, for anybody out there who would like to get a hold of you, could you just talk about your legal consulting, your nurse consulting that you do and how people can contact you if they want to talk to you about it?

Smith: And we’ll be putting that contact information across the screen for the video viewers as well.

Michelle: Great. Great. Sure. I’ve been a legal nurse consultant since 2004. I started reviewing medical records for both plaintiff and defense. I enjoy the work because I use a lot of my cases for educational purposes to teach nursing students how to stay out of court and it’s been very beneficial and it even helped some of our other nurses in the hospital setting when I was doing some teaching, keeping up with new practice, newfound things, new techniques and how to also stay out of court, and I love it. And it’s a great opportunity to educate.

So with that, I am – I don’t use Twitter or some of the social medias that some other people use today. I strictly just use email and my cell phone. I’d be happy to provide that for you.

Schenk: Go ahead.

Smith: Please do.

Michelle: Okay. It’s Michelle Glower, and that’s spelled michelleglowerrn@gmail.com.

Schenk: Oh, you must have been an early adopter to the Gmail. That’s pretty good. You don’t have any numbers, any symbols.

Michelle: Yes. Well I think nobody has that name – Glower.

Schenk: Yeah.

Smith: Yeah, you’re very fortunate. My name is Schenk Firm, so you can imagine that I’m never the first person to get anything.

Schenk: And what’s the phone number that people can call you at, Michelle?

Michelle: Sure. It’s area code (312) 406-1239.

Schenk: Great.

Michelle: And I do text.

Schenk: All right. Well Michelle, like Will said, we’ll have the information on the screen and we’ll have it up on the episodes on how to get in contact with you, but we appreciate you coming on and sharing your knowledge. I think our audience is going to really appreciate it.

Michelle: Thank you so much for having me. I thoroughly enjoyed it.

Smith: All right, thank you, Michelle.

Schenk: Thank you so much.

Michelle: Take care, bye-bye.

Schenk: Bye-bye. Yes. Traches. Traches.

Smith: My heart goes out to anybody that has any type of -ostomy. The root is stoma, and it is the small hole that goes into the body. If you have a colostomy bag, the stoma is one that goes into your intestines so that you can defecate into a bag instead of the typical route because something’s happened. With a tracheostomy, the stoma is up here in the trach, and it’s an issue because it’s something that has to constantly be cleaned. It is an enormous burden. I also happen to think it’s something we ought to look back on 100 years from now in the same way we look back at Civil War medicine. Do you know what I mean?

Schenk: Yeah.

Smith: But yeah, it’s an important issue and she brings up some very good points.

Schenk: That’s right. If you enjoyed this episode, you can listen to other episodes at our website, which is NursingHomeAbusePodcast.com, or on our YouTube channel. Or you can catch fresh episodes hot off the presses every Monday morning wherever you get your podcasts on. And with that, we’ll see you next time.

Smith: See you next time.