Answer: Great question! The short answer is that a medical directive does not exist. In fact, it has been years since the gap has been noted in both the BLS Patient Care Standards (BLS-PCS) for the management of patients with tracheostomies and the ALS-PCS (your medical directives) for the suctioning of patients with tracheostomies.
The BLS-PCS provides paramedics with the direction as to when it is appropriate to suction a patient but does not address patients with tracheostomies specifically:
“Position the patient as required to support, protect, improve and/or promote C-Spine alignment, airway patency and breathing, with attention to suctioning of saliva, blood and vomitus where necessary.” (Basic Life Support Patient Care Standards- January 2007, Version 2.0, Section 1- General Standards of Care, page 1-8).
The BLS Standards do not speak specifically on “how to” suction a patient with a stoma or a tracheostomy (as is also the case with “how to” perform other procedures – e.g. inserting an airway, placing a patient on a backboard, etc.). It is expected that paramedic students receive this training as part of the curriculum of their PCP program.
In this regard, The Prehospital Emergency Care Syllabus, which outlines the professional competencies required for current practice as a PCP, speaks to suctioning in Section 3-Systems and Associated Pathological Problems.
Section 3, 15(a) – Summarize the indications and explain the rationale for oral, nasal, pharyngeal and tracheal bronchial suctioning of a patient.
Section 3, 15(b) – Describe the techniques, precautions and vacuum levels to be utilized with each type of suctioning listed in 15(a).
Section 3, 17(c) – Describe the method to be utilized when suctioning a patient with a tracheostomy/stoma.
Paramedics performing deep suctioning of patients with tracheostomies would most likely require a medical directive as putting an instrument beyond the level of the larynx is listed as a controlled medical act. For this reason, work is underway at the Ontario Base Hospital Group to develop a medical directive to address this very gap.
At this time, we suggest discussing with the health care team your concerns regarding the possible need for suctioning during transport and the need for an escort who can perform the procedure.
It is anticipated that in the future, that both the BLS-PCS and the ALS-PCS will address patient with tracheosptomies and their unique needs.
As for the second portion of your question, this speaks to inter-facility transports and the scope of practice of paramedics vs the responsibility of the sending physician to ensure that the patient is managed safely during transport. This is an enormously complex topic and not easily answered through the ASKMAC forum. We have attempted in the past to answer this and other similar questions. Ultimately, the sending physician is responsible for the welfare of the patient on transport and the role of appropriate medical escorts. However, when situations have arisen in the past, crucial conversations as to the various escorts that may be available to assist you (RT, RN, MD, Ornge) have led to enhanced patient safety on transport. Your supervisor and or the Base Hospital Physician may also be a useful resource if you are confronted with a transport where you feel the patient may benefit from an enhanced scope of practice. The Base Hospital will stand behind you in addressing safety concerns you may have when asked to transfer an unstable patient you feel requires additional medical escorts.
If this is not an inter-facility transport but rather a 911 response for a chronic vented patient then there may not be any additional resources to send with the patient from the sending (non-hospital) facility. Chronic mechanically vented patients are being managed in the community with increasing frequency highlighting the need for further medical direction for these patients. Should the responding paramedic team be required to suction the tracheotomy and bag the patient to the receiving ED, then at this time paramedics are expected to provide this care to the best of their abilities and to the limit of their respective scopes of practice and training.