How long for a tracheostomy stoma to heal over? & PALS?
Discussion
Hi, Getting fed up of this now, and was wondering how long these normally take to heal?
I went into hospital on 29/09 for minor surgery on my eardrum, it all went tits up after they put me under general anaesthetic and the paralysing drugs, and they could not intubate me, (possibly use of a different type of anaesthetic) they then did an emergency tracheostomy.
The tube was removed on monday 2/10 and left to heal on its own.
Any ideas how long these normally take to fully heal?
I was told by my surgeon they will investigate and send a report to me, but it has been mentioned I should get the PALS service involved so that it doesn't get swept under the carpet? any suggestions/help?
Not due back to ENT til 16/11.
I went into hospital on 29/09 for minor surgery on my eardrum, it all went tits up after they put me under general anaesthetic and the paralysing drugs, and they could not intubate me, (possibly use of a different type of anaesthetic) they then did an emergency tracheostomy.
The tube was removed on monday 2/10 and left to heal on its own.
Any ideas how long these normally take to fully heal?
I was told by my surgeon they will investigate and send a report to me, but it has been mentioned I should get the PALS service involved so that it doesn't get swept under the carpet? any suggestions/help?
Not due back to ENT til 16/11.
I'll answer the second part first if I may, as that is my specialism...
An incident report should be made for a can't intimate/ can't ventilate situation. This means it will be investigated as a minimum within the surgery division. A root cause analysis will he carried out, however this is really just to assess whether there is any learning for the trust/staff involved, not so much for you. Surgeons, tending as they do to deal with difficult stuff have a habit of under reporting incidents so it may not be investigated as thoroughly as you'd expect.
Speak to PALs and raise a complaint, not so much to "complain" more to register your voice as an interested party in the incident, thisaybwell trigger a "serious incident" investigation, the fIndings of which must be shared with the CCG within 60 days and with you 10 days after the investigation is completed. This should be carried out by investigators from outside of the division in the hope of gaining some impartiality.
They won't investigate a complaint until an incident investigation has been completed, so it's a Lon drawn out process. PALs are usually pretty good, but you may need to keep in regular contact as staff are often part time and you will be one person on a big case load!
As for the trachy, variety of factors affect healing rates but if it is still open after 3 weeks I'd assume it will need further intervention. It's quite Big hole and there is not a huge Ammount of tissue there somit may take a while, keep a close eye on it though as infection could
Take hold quickly.
An incident report should be made for a can't intimate/ can't ventilate situation. This means it will be investigated as a minimum within the surgery division. A root cause analysis will he carried out, however this is really just to assess whether there is any learning for the trust/staff involved, not so much for you. Surgeons, tending as they do to deal with difficult stuff have a habit of under reporting incidents so it may not be investigated as thoroughly as you'd expect.
Speak to PALs and raise a complaint, not so much to "complain" more to register your voice as an interested party in the incident, thisaybwell trigger a "serious incident" investigation, the fIndings of which must be shared with the CCG within 60 days and with you 10 days after the investigation is completed. This should be carried out by investigators from outside of the division in the hope of gaining some impartiality.
They won't investigate a complaint until an incident investigation has been completed, so it's a Lon drawn out process. PALs are usually pretty good, but you may need to keep in regular contact as staff are often part time and you will be one person on a big case load!
As for the trachy, variety of factors affect healing rates but if it is still open after 3 weeks I'd assume it will need further intervention. It's quite Big hole and there is not a huge Ammount of tissue there somit may take a while, keep a close eye on it though as infection could
Take hold quickly.
JDiz said:
Not sure if it has already been? I was also moved to post op critical care
this is from my discharge:
Not much raises my pulse in theatre, I'm a trauma surgeon, but reading that print out is really quite dramatic. I don't know how you got into that place and I cannot judge, but the succeeding actions saved your life. I know no more about the facts than what you have said and I offer no opinion on it. this is from my discharge:
SantaBarbara said:
Make sure that it is logged as a Critical Incident or whatever the terminology is.
Why?To be honest you should have had the opportunity to speak to a senior anaesthetist and a senior surgeon and be given a full explanation of what happened as well as a plan for any surgery/anaesthetic you may need in the future
Without knowing the facts you either had a lucky escape helped by the care of a slick team at the peak of their game or something else
Speak to PALS tomorrow
Good luck and heal fast
"No cuffed tracheostomy tubes available on emergency set"
I take that to mean the cuffed trachys would have been the better option? If so, a complaint through PALS may end up with a procedure in place to ensure the cuffed ones are always available, for example. The complaint won't help you necessarily, other than a further explanation of what happened, but may prevent something similar happening to somebody else. It's worth doing, it's how hospitals improve.
I take that to mean the cuffed trachys would have been the better option? If so, a complaint through PALS may end up with a procedure in place to ensure the cuffed ones are always available, for example. The complaint won't help you necessarily, other than a further explanation of what happened, but may prevent something similar happening to somebody else. It's worth doing, it's how hospitals improve.
Edited by Brainpox on Tuesday 17th October 22:44
I did speak to a senior surgeon (my ent surgeon)and senior anaesthetist, they were having a meeting a couple of weeks ago to discuss, I haven’t heard since. As I still need the ear surgery so need to avoid it happening again obviously.
Side note, I have had two prev generals this year with no issues.
Unsure about the cuffed trachy as when I was in CCU I definitely had a cuffed one. They deflated it and fitted a passy-Muir valve for a day before removing the trachy. Maybe they changed it in recovery. I don’t remember.
The doc, yes they told me I was lucky I was in ENT and saved my life.
Side note, I have had two prev generals this year with no issues.
Unsure about the cuffed trachy as when I was in CCU I definitely had a cuffed one. They deflated it and fitted a passy-Muir valve for a day before removing the trachy. Maybe they changed it in recovery. I don’t remember.
The doc, yes they told me I was lucky I was in ENT and saved my life.
Edited by JDiz on Wednesday 18th October 07:11
f
k a duck, that's about as close to the pearly gates as you can get and still manage the return journey.
If the rest of you is well, your trachy site should heal really quickly - there are always exceptions to this (just normal human variation not problems) but I've had a couple of vaguely similar holes in me (suprapubic catheter, twice, and gastrostomy - in each case it's a large puncture wound through multiple layers of stuff and only held open by the tube) and when the tube comes out before the stoma has really healed the body usually seems to crack on with it VERY fast, hours to days for it to close-ish such that you wouldn't be able to get the tube back in and days to weeks for it to not really need the dressing or anything.
A mate was looked after at St George's which has a long term ventilator unit or something of that ilk, based on which I suspect their post decannulation info sheet is likely to be good quality and trustworthy.
Wishing you fast mending!
k a duck, that's about as close to the pearly gates as you can get and still manage the return journey.If the rest of you is well, your trachy site should heal really quickly - there are always exceptions to this (just normal human variation not problems) but I've had a couple of vaguely similar holes in me (suprapubic catheter, twice, and gastrostomy - in each case it's a large puncture wound through multiple layers of stuff and only held open by the tube) and when the tube comes out before the stoma has really healed the body usually seems to crack on with it VERY fast, hours to days for it to close-ish such that you wouldn't be able to get the tube back in and days to weeks for it to not really need the dressing or anything.
A mate was looked after at St George's which has a long term ventilator unit or something of that ilk, based on which I suspect their post decannulation info sheet is likely to be good quality and trustworthy.
Wishing you fast mending!
FlyingMeeces said:
fk a duck, that's about as close to the pearly gates as you can get and still manage the return journey.
If the rest of you is well, your trachy site should heal really quickly - there are always exceptions to this (just normal human variation not problems) but I've had a couple of vaguely similar holes in me (suprapubic catheter, twice, and gastrostomy - in each case it's a large puncture wound through multiple layers of stuff and only held open by the tube) and when the tube comes out before the stoma has really healed the body usually seems to crack on with it VERY fast, hours to days for it to close-ish such that you wouldn't be able to get the tube back in and days to weeks for it to not really need the dressing or anything.
A mate was looked after at St George's which has a long term ventilator unit or something of that ilk, based on which I suspect their post decannulation info sheet is likely to be good quality and trustworthy.
Wishing you fast mending!
Was it really that bad? coming from someone with no medical knowledge.k a duck, that's about as close to the pearly gates as you can get and still manage the return journey.If the rest of you is well, your trachy site should heal really quickly - there are always exceptions to this (just normal human variation not problems) but I've had a couple of vaguely similar holes in me (suprapubic catheter, twice, and gastrostomy - in each case it's a large puncture wound through multiple layers of stuff and only held open by the tube) and when the tube comes out before the stoma has really healed the body usually seems to crack on with it VERY fast, hours to days for it to close-ish such that you wouldn't be able to get the tube back in and days to weeks for it to not really need the dressing or anything.
A mate was looked after at St George's which has a long term ventilator unit or something of that ilk, based on which I suspect their post decannulation info sheet is likely to be good quality and trustworthy.
Wishing you fast mending!
No answer at PALS today.
Thanks for the st georges link.
Difficult airway society can't intubate, can't ventilate guidelines: https://www.das.uk.com/guidelines/das_intubation_g...
An emergency tracheostomy is the final step after which there are no answers. You've been very fortunate although to some extent all anaesthetists have training in this process, soe being more comfortable than others with the process. CICV is a recognised issue with anaesthesia and not related to negligence or ability.I cant tell yoy why this last anaesthetic was different to the previous two without more detail.
An emergency tracheostomy is the final step after which there are no answers. You've been very fortunate although to some extent all anaesthetists have training in this process, soe being more comfortable than others with the process. CICV is a recognised issue with anaesthesia and not related to negligence or ability.I cant tell yoy why this last anaesthetic was different to the previous two without more detail.
Quick update, pals weren't great, they just passed a message on to ENT for them to call me, in the mean time the anaesthetist report arrived this morning. ENT surgeon is bringing my appt forward by a couple of weeks.
The medical staff here may make more sense of the report than me.
The medical staff here may make more sense of the report than me.
Edited by JDiz on Friday 20th October 14:03
The_Doc said:
Are you looking for
a) blame
b) explanation
c) future safety
d) money
e) sense of it all...
or just How long for a tracheostomy stoma to heal over?
ba) blame
b) explanation
c) future safety
d) money
e) sense of it all...
or just How long for a tracheostomy stoma to heal over?
c
e
I have no intention of suing, as far as I can see there was no negligence, as I understand it was part the new anaesthetic and part my body being awkward?
Obviously I an worried about c. as I am due to retry the ear op in the near future.
and just iooking to vent, I was asking about the stoma, as tbh I fancy shooting off to the bahamas to relax before the retry, but pointless going when i cant get sea or sand near it.
JDiz said:
Quick update, pals weren't great, they just passed a message on to ENT for them to call me, in the mean time the anaesthetist report arrived this morning. ENT surgeon is bringing my appt forward by a couple of weeks.
The medical staff here may make more sense of the report than me.
So in English:The medical staff here may make more sense of the report than me.
Edited by JDiz on Friday 20th October 14:03
You were admitted on th 29th September for an ENT procedure and before they put you to sleep they gave you lots of oxygen to give them as much time as possible to put an airway in. At that time they could see carbon dioxide coming back into the mask when you breathed out so the oxygen was definitely getting to your lungs.
When they put you to sleep they gave you some drugs, one of which (Remifentanil) you hadn't had before and may have put your chest muscles into spasm. At that time for a number of reasons they could not get oxygen into you despite a variety of manoeuvres. (At this point they probably get the ENT surgeon in).
It was decided that as they couldn't oxygenate you normally they would try and put a tube in your mouth through your vocal cords to try and get air in that way. They couldn't see your larynx when looked and they couldn't pass a plastic rod into your voice box (which can be used to help). At this point they correctly realised the only option was to make a hole in your neck so you could breath.
After this was done the ENT surgeon looked to work out why this had happened and his impression was that:
1) Your jaw doesn't move much
2) The epiglottis which sits ontop of your voice box is quite floppy so was coving the view of the voice box.
3) Because of 2) they could only partially see the back of the larynx making it impossible to pass and airway normally.
They have concluded if you were to need surgery in the future you will need to have the tube passed into your larynx while awake using a camera and that they should avoid Remifentanil.
I hope that answers b) c) and e) .
Thanks for that, explains it much better.
I have actually just received a pm from an anaesthetist who wishes to remain anonymous, which has come as a bit of a shock. Does the below seem correct?
I have actually just received a pm from an anaesthetist who wishes to remain anonymous, which has come as a bit of a shock. Does the below seem correct?
anonymous said:
TBH there are a number of points in the anaesthetic statement that I take issue with and despite being no fan of litigation culture I would advise you to get some legal representation.
You received a very large dose of Propofol (dose usually 2-3mg/kg) which could be for a number of reasons but it was the Remifentanil which is unusual. Its been established for almost 20 years and most people would use it with an infusion pump not as a bolus and would also more conventionally use it as part of a different anaesthetic technique than the one I think had been planned for you. We use computer controlled infusion pumps now but back in the day had to give a manual bolus of 0.5mcg/kg over 30 seconds.
So unless you're 200kg you received a very big bolus and I would have to ask if it was given manually not in a controlled manner by pump.
My other point is that you were given a muscle relaxant after the tracheostomy was performed and not before which goes against the national guidelines referred to by another poster on the thread. It is by no means certain it would have made a difference however in theory it can and most experienced anaesthetists would have done so. Theoretically this could have brought control to the situation and given enough time for things to have been done differently avoiding the trace completely. Obviously this is conjecture though.
You received a very large dose of Propofol (dose usually 2-3mg/kg) which could be for a number of reasons but it was the Remifentanil which is unusual. Its been established for almost 20 years and most people would use it with an infusion pump not as a bolus and would also more conventionally use it as part of a different anaesthetic technique than the one I think had been planned for you. We use computer controlled infusion pumps now but back in the day had to give a manual bolus of 0.5mcg/kg over 30 seconds.
So unless you're 200kg you received a very big bolus and I would have to ask if it was given manually not in a controlled manner by pump.
My other point is that you were given a muscle relaxant after the tracheostomy was performed and not before which goes against the national guidelines referred to by another poster on the thread. It is by no means certain it would have made a difference however in theory it can and most experienced anaesthetists would have done so. Theoretically this could have brought control to the situation and given enough time for things to have been done differently avoiding the trace completely. Obviously this is conjecture though.
JDiz said:
Thanks for that, explains it much better.
I have actually just received a pm from an anaesthetist who wishes to remain anonymous, which has come as a bit of a shock. Does the below seem correct?
I don't know to be honest. I'm an junior ENT surgeon so don't get involved in the nitty gritty of the anaesthetics. I know the difficult airway guidelines enough to know when to do a trachy and how to do it but not the steps before. I have actually just received a pm from an anaesthetist who wishes to remain anonymous, which has come as a bit of a shock. Does the below seem correct?
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